EYE MOVEMENT
JAMES
DESENSITIZATION: EVIDENCE D. HERBERT Medical
Summary-The scientific (EMD). a novel intervention sparse research conducted conclusions regarding the uncritically accepting the
College
A CRITIQUE
OF THE
and KIM T. MUESER of Pennsylvania/EPPI
evidence supporting the efficacy of eye movement desensitization for traumatic memories and related conditions. is reviewed. The in this area has serious methodological flaws. precluding definite effectiveness of the procedure. Clinicians arc cautioned against clinical efficacy of EMD.
Since the birth of behavior therapy over 30 years ago its practitioners have challenged the long-cherished belief that years of intensive psychotherapy are required to produce significant changes in psychopathology. Indeed, the search for empirically validated interventions grounded in learning theory that produce rapid clinical improvements has been a guiding principle of behavior therapy. Consistent with this tradition, Shapiro (1989a) recently introduced a novel treatment for traumatic memories and associated difficulties (e.g., posttraumatic stress disorder: PTSD) referred to as eye movement desensitization (EMD). In the few years following the development of EMD, there has been a phenomenal surge in interest in the technique with training opportunities available world-wide. In concert with the growing popularity of the procedure, impressive claims for its efficacy have been made. For example, Wolpe has stated that EMD “has all the indications of being a major new resource in behavior therapy” (EMDR 1991-1992 National Training Schedule). Given the widespread attention to EMD, a critical appraisal of the evidence supporting its efficacy is timely. In the present review we briefly describe the development of EMD, followed by an evaluation of research supporting the clinical efficacy
of the procedure. We conclude with a discussion of the need for further research in this area and caution against uncritically accepting claims regarding the efficacy of EMD.
The Origin
of Eye Movement Desensitization and Reprocessing
Shapiro (1989b) traces the development of the EMD technique to a serendipitous observation that her own disturbing thoughts disappeared from awareness when her eyes manner,” moved rapidly in “a multi-saccadic and that when she subsequently retrieved those thoughts, they were no longer disturbing. Following this observation, Shapiro developed the EMD procedure as a standardized clinical intervention to treat persons with disturbing thoughts and memories, particularly those secondary to traumas such as assault, rape, accidents, and combat exposure. The essence of the EMD procedure consists of having the client visualize the traumatic event while simultaneously tracking the therapist’s finger as it is moved rapidly from side to side in sets of 10 to 30 strokes. When the unpleasant feelings associated with the memory of one traumatic image have been alleviated, a second memory is
Address correspondence and reprint requests to James D. Herbert. Department Pennsylvania/EPPl. 3200 Henry Ave., Philadelphia, PA 19129. U.S.A.
of Psychiatry.
Medical
College
of
I70
JAMES
D. HERBERT
treated, and so on until no unpleasant feelings about traumatic memories remain. According to initial reports, one session of EMD is usually sufficient to eliminate permanently traumatic, long-standing memories that have been personally disruptive and have interfered with interpersonal functioning (Shapiro, 1989a,b).
Research
on the Efficacy of EMD
Five studies on the efficacy of EMD for the treatment of traumatic memories and other psychopathology have been published in pecrreviewed journals, including one controlled study and four case studies. We first describe and critique the controlled study. followed by the case reports. Shapiro (1989n) randomly assigned 22 persons with histories of trauma to receive one session of EMD or a control treatment. All assessments and treatment were conducted by the author. For the EMD group. treatment was provided as described above. For the control group, patients recounted thei memories witho14t engaging in traumatic therapist-directed eye movements. Heart-rate was monitored for patients receiving EMD but not for patients in the control group. Immediately following the SO minute treatment session, patients in the control group received one session of EMD. Assessments were conducted prior to treatment, throughout the treatment session, and at l- and 3-month follow-ups on the following measures: Subjective Units of Disturbance Scale (SIJDS. an 1l-point Likcrt scale), ratings of the credibility of positive. empowering thoughts related to the trauma (Validity of Cognitions Scale, VCS: a 7-point Likert scale), and patients’ descriptions of their symptoms. More specifically, symptoms wcrc assessed by interviews conducted with the patient and sometimes with significant others before and after treatment and at the follow-up assessments. In addition to prc-session, postsession, and follow-up assessments, SUDS ratings were also obtained for both treatment groups throughout the treatment session. For
and
KIM T. MUESER
the EMD group, the VCS was given after each SUDS rating. For the control group, however, the VCS was root given after the SUDS ratings during the control treatment session. It is noteworthy that the EMD treatment was terminated only after SUDS ratings for all traumas achieved a criterion level of “0” or “I” (low anxiety) utzd VCS ratings reached the level of “6” or “7” (high validity of positive thoughts). The results indicated that, as expected, patients who received the EMD procedure showed dramatic improvements on SUDS and VCS ratings over the treatment session, whereas patients who received the control procedure showed no significant improvements in these measures. When the control group received EMD, they experienced similar improvements in SUDS and VCS ratings. These improvements were maintained at both follow-up assessments. Additionally. presenting symptoms improved following EMD, and these gains were maintained at follow-up. Although at first glance these results appear impressive. the study has serious methodological problems. All of the assessments were based on verbal reports of the patient to the therapist (author), suggesting that demand characteristics could have played a role in the obser\,ed improvements. This is of special concern considering that the EMD procedure was conducted in such a way that all patients were rcqGrerf to demonstrate significant reductions in SUDS ratings and improvements in VCS ratings before treatment was terminated. In contrast, the control treatment was provided irrespective of the SUDS and VCS ratings. The monitoring of heart-rate for the EMD procedure, but not the control procedure. may have also contributed to differential expectations for improvement between patients receiving the two treatments. This suggests that the therapist may have communicated to the patient during treatment an expectation for change in one condition (EMD), but not the other (control). no standardized instruments Furthermore. were used to measure symptomatology or
Eye
Movement
social adjustment (e.g., self-report measures such as the Symptom Checklist-90 or the Beck Depression Inventory, semi-structured interviews such as the Brief Psychiatric Rating Scale). Thus, a major problem with this study is that neither objective (i.e., conducted by a blind assessor) nor standardized assessments were obtained of the major variables of interest (i.e., symptomatology), and the SUDS and VCS ratings may have been confounded by demand characteristics inherent in combining the EMD procedure with the assessment of these domains. The fact that all treatment and assessments were conducted by the author, who originated the EMD procedure, also raises the possibility of unintentional experimenter bias effects. A final consideration is the diagnostic status of the patients. Although all patients were reported to have been bothered by traumatic memories, the absence of structured diagnostic interviews makes it impossible to know how many of the participants met DSM-III-R criteria for PTSD. In summary, although this study is suggestive, its methodological problems preclude drawing conclusions regarding the efficacy of EMD. Shapiro (1989b) has also presented a case report of the application of EMD for the treatment of PTSD. The client was a 63-yearold woman who reported intrusive thoughts, flashbacks, nightmares, and other symptoms of PTSD that had been experienced subsequent to a rape which had occurred 1.5 months before. Following one 50 minute session of EMD in which three related memories were treated, the patient reported experiencing no anxiety about the trauma. At a follow-up assessment conducted 3 months later the patient reported that all of her symptoms had ceased immediately following the EMD session and there had been no recurrences. Once again, these results are impressive. However, interpretation of this case report is problematic because of lack of attention to methodological considerations in single case psychotherapy research (cf. Barlow & Hersen, 1984). As with the Shapiro (1989a) study, no standardized
Desensitization
171
instruments were employed to assess changes in symptomatology or other domains of functioning. Multiple baseline assessments were not conducted to establish the stability of the presenting symptoms prior to treatment. Lastly, no attempt was made to establish psychiatric diagnosis. Although this case report was presented mainly for illustrative purposes, the absence of objective assessments of the patient’s psychopathology renders this report questionable about the efficacy of EMD. A second case report of EMD was published by Wolpe and Abrams (1991). The authors described the treatment of a 43-year-old woman with symptoms of PTSD stemming from a rape 9 years earlier. Prior to EMD various interventions, including supportive therapy, psychodynamic psychotherapy, and homeopathic intervention had resulted in only minimal improvement in symptoms. After 15 sessions of behavior therapy, at least 11 of which had consisted largely of EMD, full remission of symptoms was achieved. As with the Shapiro (1989b) report, this case study is limited by the lack of either objective or standardized symptom assessments, the absence of multiple baseline assessments to determine stability of symptomatology, and questions regarding psychiatric diagnosis. Two similar case studies of EMD were published by Puk (1991). One case involved the EMD treatment of a 23-year-old woman with a history of childhood sexual abuse. and the other case was a 33-year-old woman with traumatic memories of her dying sister. A single treatment session of EMD was successful at eliminating long-standing symptoms, and the treatment effects were maintained at 1 year (sexual abuse case) and 6 months (dying sister case). These case reports have the same limitations as the previous case studies of EMD, most notably the lack of objective, independent assessments of symptoms. Hence, this study too does not provide compelling evidence for the efficacy of EMD. Marquis (1991) recently described his use of EMD for the treatment of 100 patients with
172
JAMES
D. HERBERT
various forms of psychopathology presumed to be secondary to the past experience or anticipation of traumatic events. Distressing experiences related to current symptoms were generated by each patient then targeted with EMD (e.g., upsetting thoughts about past Christmases, distress over a pet’s death). The outcome of EMD treatment was rated by the clinician at follow-ups ranging from 1 week to 1 year posttreatment on a four-point scale ranging from 0 (“unchanged”) to 3 (“cured or nearly cured”). Of the original sample, 22 patients either refused the treatment or dropped out prematurely. Overall, of the 7X patients who received EMD treatment, there was a mean improvement rating of 1.85 on the 3point scale, indicating significant clinical improvement. As with the previous research reviewed above, this study is limited by a variety of methodological shortcomings. All treatment and assessment was conducted by the author/ clinician and no objective and/or standardized measures of psychopathology were obtained. EMD treatment was not compared with other treatment methods or control conditions, either within or between subjects. Finally. no information was given about how diagnoses were established. The report also raises questions about how EMD was implemented. It is unclear how many sessions of EMD each patient received. and most patients were also receiving a variety of other interventions concurrently. Thus, it is possible that clinical improvements in these 7X patients were produced by the ancillary treatments and not by EMD. Finally, impressive claims are made about the successful treatment of some notoriously treatment-resistant clinical phenomena (e.g., eliminating the delusions of one patient with paranoid schizophrenia and another patient with psychotic depression, healing stocomplete recovery of severe mach ulcers, childhood depression in a single session of EMD). Although we do not rule out the possibility of such results. they do raise questions about the objectivity of the assessments.
and
KIM T. MUESER
the stability of treatment gains, the accuracy of the diagnoses, and ultimately, the clinical effects of EMD.
Summary
and Recommendations
Our review of research on EMD indicates that all of the studies share a common set of methodological problems, the most significant of which is the absence of objective assessments of symptoms. Objective evaluation of patient psychopathology is perhaps the single most important factor in evaluating a clinical research report. Considering the lack of diagnostic information in these studies and the possibility that many patients had subclinical syndromes, the potential for unintentional therapist bias when evaluating their own clinical performance would appear to be high. As objective reviewers of the research literature, we do not find that the results of these studies provide a sound scientific basis suggesting that EMD is an effective clinical innovation. Most of the research on EMD has been based on case reports. Case studies are a valuable part of the scientific investigation of novel psychotherapeutic interventions. and they have played an important role in the development of many behavioral strategies and medical interventions. Designs for single subject research in behavior therapy have been described in detail by Barlow and Hersen (1984) and Kazdin (lYX2) and have been illustrated for exposure treatment of PTSD by Mueser, Yarnold. and Foy (1991). among others. The case reports published on the efficacy of EMD, however, do not take advantage of the variety of design options available to clinical investigators interested in single case research. Consequently, the case studies on EMD contribute little knowledge about the efficacy of this approach. The lack of diagnostic information about patients receiving EMD does not challenge the validity of the intervention itself. but it leaves open the question of
Eye
Movement
the nature of the patient population that has received treatment. Despite the lack of scientifically adequate support for EMD, strong claims have been made as to its efficacy. Shapiro (1989b) asserts that “the evidence clearly indicates that a single session of the EMD procedure is effective in desensitizing memories of traumatic incidents and changing the subjects’ cognitive assessments of their individual situations,” and “it is apparent that the EMD procedure is extremely effective in desensitizing traumatic memories characteristic of PTSD and eliminating attendant complaints” (Shapiro, 1989a). Similarly, Solomon (1991) has described it as “a powerful tool that rapidly and effectively reduces the emotional impact of traumatic or anxiety evoking situations.” Lipke (1991) has stated that it is “by far the most effective and efficient treatment we have ever used with dissociative episodes, intrusive memories, and nightmares with Vietnam combat veterans.” Furthermore, the technique has recently been promoted as a treatment for other problems, such as anxiety disorders other than PTSD. personality disorders, multiple personality and other dissociative disorders, and the problems of adult children of alcoholics. Dr. Shapiro has recently renamed the procedure “eye-movement desensitization and reprocessing (EMDR)” to subsume additional procedures (which indirectly reinforces some of our concerns). Training opportunities in EMDR have become widely available in the U.S.A., Israel, Korea, Canada, El Salvador, Germany, Australia, Nicaragua, and Guatemala. Dr. Shapiro has developed a series of workshop programs to train and formally “certify” licensed mental health professionals in the technique. Participants in an initial twoday “Level I Basic Training” workshop are introduced to the EMDR technique. Level I graduates are encouraged to attend a subsequent two-day Level II workshop in order to obtain “a full understanding of the therapeutic utilization and myriad applications of EMDR” (EMDR Newsletter, 1991). Those who com-
Desensitization
173
plete the Level II workshop are awarded a “Certificate of Completion,” indicating their “competence” to use EMDR. Clinicians who attend the workshops are required to sign a statement that they will not train others in the method or even allow others to view printed materials distributed in the programs (see also Shapiro, 1991, for a cautionary statement about the use of EMDR by non-trained clinicians). Whereas this procedure is justified to maintain “quality control,” such a restriction of information runs counter to the principle of the open and free exchange of ideas among scientists and professionals. EMDR is also being promoted through a variety of other channels. The EMDK Network Newsletter is available to clinicians at a cost of $50 per year. Plans for a computer bulletin board arc currently under way. Presentations on EMDR have been made at professional meetings, including the Association for the Advancement of Behavior Therapy (AABT) and the American Psychological Society. Interest in both research and clinical applications of EMDR is reflected in the formation of special study groups throughout the United States. The widespread dissemination of EMDR appears premature in view of the lack of scientifically adequate support for the technique. Historically. behavior therapists have required such support as a condition for the adoption of clinical strategies, while recognizing that the exigencies of clinical practice dictate that the competent clinician must sometimes use unproven methods, and that clinical innovation is necessary for the field to progress. Ultimately. the clinician must deal with the issue of how to select treatment techniques with the highest probability of success. We propose that the most judicious strategy for making this decision is first to select techniques supported by rigorously conducted clinical research (when such techniques are available), and second to try innovative strategies when more demonstrated methods are unsuccessful
JAMES
174
D. HERBERT
or meet with limited success. In the case of PTSD, imaginal exposure (flooding) and stress inoculation training have been demonstrated to have a beneficial and durable impact on objective assessments of symptomatology (Keane, Fairbank, Caddell, & Zimmering, 1989; Cooper & Clum, 1989; Foa, Rothbaum, Riggs, & Murdock, 1991). Not every patient with PTSD responds to imaginal exposure treatment or stress inoculation training (e.g., Mueser et al., 1991). However, we believe that the strong empirical support for these interventions, in contrast to EMDR, should make them the treatments of choice for this and similar disorders (e.g., “traumatic memories”). Until the results bf more methodologically sound studies are available, we recommend that clinicians approach the use of EMD with due reserve. 1* Acknoi&dgemerrrs - Gratitude is exprcsscd to Alan S. Bellack and Edna B. Foa for their helpful comments on an earlier draft of this article.
and
KIM T. MUESER
Foa. E. B.. Rothbaum. B. O., Riggs, D. S., & Murdock, T. B. (1991). Treatment of posttraumatic stress disorder in rape victims: A comparison between cognitivebehavioral procedures and counseling. Jourt~al of‘ Consuiting
Kazdin, Methods
and’ Clinical
Psychology, 59,715-723. Sin&case research desi,w.c: forclinical ;nd applied settings. New York:
A.
E.
(1082).
Oxford University Press. Keane. 1‘. M., Fairbank. J. A., Caddell, J. M.. & Zimering, R. T. (IYSY). Implosive (flooding) therapy reduces symptoms of PTSD in Vietnam combat veterans. Behavior Therapy, 20, 245-260. Lipke. H. (IYYl. October). Cited in Eve Movement Desensirizaliorz urld Reprocessing IW-IW.? trainirlg schedule. Palo Alto, CA. Mental
Institute. Marquis, J. N. (1991). A report on seventy-eight cases treated by eye movement desensitization. Jownul- oj Behavior Therapy and Experimental Psychiatry, 22, l87192. Mueser. K. T., Yarnold, P. R.. & Foy, 0. W. (IYYI). Statistical analysis for single-case designs: evaluating outcome of imaginal exposure treatment of chronic PTSD. Behavior Modificariotz. 15. 134-155. Puk. G. (IYYI). Treating traumatic memories: a case report on the eye movement desensitization procedure. Journal of Behavior Therapy und Esperimentcrl P.svchiairv. -7.2. 140-151. Shapiro. F. (IYXYn). Eye movement dcscnsitization: A new treatment for post-traumatic stress disorder. Jourmrl of Behu\lior 20. 21 I-217.
D.
e.rperimer~fal
H..
&
Hcrscn.
desi,qu
(second
M.
Therrrpy
and
Esperimcwrtrl
P.swhrrrlry.
Shapiro, F. (1YXYh). Efficacv of the eve movement desensitization procedure in the treatment of traumatic memories. Journal of Trcrumatic Slress. 2. 190-223. Solomon, R. (IYYl. October). Cited in Eye Movemerrr
References Barlow.
ncrliorwl
Research
Sing/e cuse New York: Perga-
(1984).
ediliotl).
mon Press. Cooper, N. A.. & Glum, G. A. (IYSY). lmaginal flooding as a supplementary treatment for PTSD in combat veterans: A controlled study. Behavior Therapy, 20. 381-391.
Desensi~izafion utld Reproceasing IWI-1992 trcrirlirlg schedule. Palo Alto, CA, Mental
rrcrriomtl
Research
Institute. Wolpe. J.. & Abrams, J. (IYYI). Post-traumatic stress disorder overcome by eye-movement desensitization: A case report. Journal q/ Behavior Therapy tmd E.rperimenial
Psvchiatry.
22,
3Y-43.
JAMES
DESENSITIZATION: EVIDENCE D. HERBERT Medical
Summary-The scientific (EMD). a novel intervention sparse research conducted conclusions regarding the uncritically accepting the
College
A CRITIQUE
OF THE
and KIM T. MUESER of Pennsylvania/EPPI
evidence supporting the efficacy of eye movement desensitization for traumatic memories and related conditions. is reviewed. The in this area has serious methodological flaws. precluding definite effectiveness of the procedure. Clinicians arc cautioned against clinical efficacy of EMD.
Since the birth of behavior therapy over 30 years ago its practitioners have challenged the long-cherished belief that years of intensive psychotherapy are required to produce significant changes in psychopathology. Indeed, the search for empirically validated interventions grounded in learning theory that produce rapid clinical improvements has been a guiding principle of behavior therapy. Consistent with this tradition, Shapiro (1989a) recently introduced a novel treatment for traumatic memories and associated difficulties (e.g., posttraumatic stress disorder: PTSD) referred to as eye movement desensitization (EMD). In the few years following the development of EMD, there has been a phenomenal surge in interest in the technique with training opportunities available world-wide. In concert with the growing popularity of the procedure, impressive claims for its efficacy have been made. For example, Wolpe has stated that EMD “has all the indications of being a major new resource in behavior therapy” (EMDR 1991-1992 National Training Schedule). Given the widespread attention to EMD, a critical appraisal of the evidence supporting its efficacy is timely. In the present review we briefly describe the development of EMD, followed by an evaluation of research supporting the clinical efficacy
of the procedure. We conclude with a discussion of the need for further research in this area and caution against uncritically accepting claims regarding the efficacy of EMD.
The Origin
of Eye Movement Desensitization and Reprocessing
Shapiro (1989b) traces the development of the EMD technique to a serendipitous observation that her own disturbing thoughts disappeared from awareness when her eyes manner,” moved rapidly in “a multi-saccadic and that when she subsequently retrieved those thoughts, they were no longer disturbing. Following this observation, Shapiro developed the EMD procedure as a standardized clinical intervention to treat persons with disturbing thoughts and memories, particularly those secondary to traumas such as assault, rape, accidents, and combat exposure. The essence of the EMD procedure consists of having the client visualize the traumatic event while simultaneously tracking the therapist’s finger as it is moved rapidly from side to side in sets of 10 to 30 strokes. When the unpleasant feelings associated with the memory of one traumatic image have been alleviated, a second memory is
Address correspondence and reprint requests to James D. Herbert. Department Pennsylvania/EPPl. 3200 Henry Ave., Philadelphia, PA 19129. U.S.A.
of Psychiatry.
Medical
College
of
I70
JAMES
D. HERBERT
treated, and so on until no unpleasant feelings about traumatic memories remain. According to initial reports, one session of EMD is usually sufficient to eliminate permanently traumatic, long-standing memories that have been personally disruptive and have interfered with interpersonal functioning (Shapiro, 1989a,b).
Research
on the Efficacy of EMD
Five studies on the efficacy of EMD for the treatment of traumatic memories and other psychopathology have been published in pecrreviewed journals, including one controlled study and four case studies. We first describe and critique the controlled study. followed by the case reports. Shapiro (1989n) randomly assigned 22 persons with histories of trauma to receive one session of EMD or a control treatment. All assessments and treatment were conducted by the author. For the EMD group. treatment was provided as described above. For the control group, patients recounted thei memories witho14t engaging in traumatic therapist-directed eye movements. Heart-rate was monitored for patients receiving EMD but not for patients in the control group. Immediately following the SO minute treatment session, patients in the control group received one session of EMD. Assessments were conducted prior to treatment, throughout the treatment session, and at l- and 3-month follow-ups on the following measures: Subjective Units of Disturbance Scale (SIJDS. an 1l-point Likcrt scale), ratings of the credibility of positive. empowering thoughts related to the trauma (Validity of Cognitions Scale, VCS: a 7-point Likert scale), and patients’ descriptions of their symptoms. More specifically, symptoms wcrc assessed by interviews conducted with the patient and sometimes with significant others before and after treatment and at the follow-up assessments. In addition to prc-session, postsession, and follow-up assessments, SUDS ratings were also obtained for both treatment groups throughout the treatment session. For
and
KIM T. MUESER
the EMD group, the VCS was given after each SUDS rating. For the control group, however, the VCS was root given after the SUDS ratings during the control treatment session. It is noteworthy that the EMD treatment was terminated only after SUDS ratings for all traumas achieved a criterion level of “0” or “I” (low anxiety) utzd VCS ratings reached the level of “6” or “7” (high validity of positive thoughts). The results indicated that, as expected, patients who received the EMD procedure showed dramatic improvements on SUDS and VCS ratings over the treatment session, whereas patients who received the control procedure showed no significant improvements in these measures. When the control group received EMD, they experienced similar improvements in SUDS and VCS ratings. These improvements were maintained at both follow-up assessments. Additionally. presenting symptoms improved following EMD, and these gains were maintained at follow-up. Although at first glance these results appear impressive. the study has serious methodological problems. All of the assessments were based on verbal reports of the patient to the therapist (author), suggesting that demand characteristics could have played a role in the obser\,ed improvements. This is of special concern considering that the EMD procedure was conducted in such a way that all patients were rcqGrerf to demonstrate significant reductions in SUDS ratings and improvements in VCS ratings before treatment was terminated. In contrast, the control treatment was provided irrespective of the SUDS and VCS ratings. The monitoring of heart-rate for the EMD procedure, but not the control procedure. may have also contributed to differential expectations for improvement between patients receiving the two treatments. This suggests that the therapist may have communicated to the patient during treatment an expectation for change in one condition (EMD), but not the other (control). no standardized instruments Furthermore. were used to measure symptomatology or
Eye
Movement
social adjustment (e.g., self-report measures such as the Symptom Checklist-90 or the Beck Depression Inventory, semi-structured interviews such as the Brief Psychiatric Rating Scale). Thus, a major problem with this study is that neither objective (i.e., conducted by a blind assessor) nor standardized assessments were obtained of the major variables of interest (i.e., symptomatology), and the SUDS and VCS ratings may have been confounded by demand characteristics inherent in combining the EMD procedure with the assessment of these domains. The fact that all treatment and assessments were conducted by the author, who originated the EMD procedure, also raises the possibility of unintentional experimenter bias effects. A final consideration is the diagnostic status of the patients. Although all patients were reported to have been bothered by traumatic memories, the absence of structured diagnostic interviews makes it impossible to know how many of the participants met DSM-III-R criteria for PTSD. In summary, although this study is suggestive, its methodological problems preclude drawing conclusions regarding the efficacy of EMD. Shapiro (1989b) has also presented a case report of the application of EMD for the treatment of PTSD. The client was a 63-yearold woman who reported intrusive thoughts, flashbacks, nightmares, and other symptoms of PTSD that had been experienced subsequent to a rape which had occurred 1.5 months before. Following one 50 minute session of EMD in which three related memories were treated, the patient reported experiencing no anxiety about the trauma. At a follow-up assessment conducted 3 months later the patient reported that all of her symptoms had ceased immediately following the EMD session and there had been no recurrences. Once again, these results are impressive. However, interpretation of this case report is problematic because of lack of attention to methodological considerations in single case psychotherapy research (cf. Barlow & Hersen, 1984). As with the Shapiro (1989a) study, no standardized
Desensitization
171
instruments were employed to assess changes in symptomatology or other domains of functioning. Multiple baseline assessments were not conducted to establish the stability of the presenting symptoms prior to treatment. Lastly, no attempt was made to establish psychiatric diagnosis. Although this case report was presented mainly for illustrative purposes, the absence of objective assessments of the patient’s psychopathology renders this report questionable about the efficacy of EMD. A second case report of EMD was published by Wolpe and Abrams (1991). The authors described the treatment of a 43-year-old woman with symptoms of PTSD stemming from a rape 9 years earlier. Prior to EMD various interventions, including supportive therapy, psychodynamic psychotherapy, and homeopathic intervention had resulted in only minimal improvement in symptoms. After 15 sessions of behavior therapy, at least 11 of which had consisted largely of EMD, full remission of symptoms was achieved. As with the Shapiro (1989b) report, this case study is limited by the lack of either objective or standardized symptom assessments, the absence of multiple baseline assessments to determine stability of symptomatology, and questions regarding psychiatric diagnosis. Two similar case studies of EMD were published by Puk (1991). One case involved the EMD treatment of a 23-year-old woman with a history of childhood sexual abuse. and the other case was a 33-year-old woman with traumatic memories of her dying sister. A single treatment session of EMD was successful at eliminating long-standing symptoms, and the treatment effects were maintained at 1 year (sexual abuse case) and 6 months (dying sister case). These case reports have the same limitations as the previous case studies of EMD, most notably the lack of objective, independent assessments of symptoms. Hence, this study too does not provide compelling evidence for the efficacy of EMD. Marquis (1991) recently described his use of EMD for the treatment of 100 patients with
172
JAMES
D. HERBERT
various forms of psychopathology presumed to be secondary to the past experience or anticipation of traumatic events. Distressing experiences related to current symptoms were generated by each patient then targeted with EMD (e.g., upsetting thoughts about past Christmases, distress over a pet’s death). The outcome of EMD treatment was rated by the clinician at follow-ups ranging from 1 week to 1 year posttreatment on a four-point scale ranging from 0 (“unchanged”) to 3 (“cured or nearly cured”). Of the original sample, 22 patients either refused the treatment or dropped out prematurely. Overall, of the 7X patients who received EMD treatment, there was a mean improvement rating of 1.85 on the 3point scale, indicating significant clinical improvement. As with the previous research reviewed above, this study is limited by a variety of methodological shortcomings. All treatment and assessment was conducted by the author/ clinician and no objective and/or standardized measures of psychopathology were obtained. EMD treatment was not compared with other treatment methods or control conditions, either within or between subjects. Finally. no information was given about how diagnoses were established. The report also raises questions about how EMD was implemented. It is unclear how many sessions of EMD each patient received. and most patients were also receiving a variety of other interventions concurrently. Thus, it is possible that clinical improvements in these 7X patients were produced by the ancillary treatments and not by EMD. Finally, impressive claims are made about the successful treatment of some notoriously treatment-resistant clinical phenomena (e.g., eliminating the delusions of one patient with paranoid schizophrenia and another patient with psychotic depression, healing stocomplete recovery of severe mach ulcers, childhood depression in a single session of EMD). Although we do not rule out the possibility of such results. they do raise questions about the objectivity of the assessments.
and
KIM T. MUESER
the stability of treatment gains, the accuracy of the diagnoses, and ultimately, the clinical effects of EMD.
Summary
and Recommendations
Our review of research on EMD indicates that all of the studies share a common set of methodological problems, the most significant of which is the absence of objective assessments of symptoms. Objective evaluation of patient psychopathology is perhaps the single most important factor in evaluating a clinical research report. Considering the lack of diagnostic information in these studies and the possibility that many patients had subclinical syndromes, the potential for unintentional therapist bias when evaluating their own clinical performance would appear to be high. As objective reviewers of the research literature, we do not find that the results of these studies provide a sound scientific basis suggesting that EMD is an effective clinical innovation. Most of the research on EMD has been based on case reports. Case studies are a valuable part of the scientific investigation of novel psychotherapeutic interventions. and they have played an important role in the development of many behavioral strategies and medical interventions. Designs for single subject research in behavior therapy have been described in detail by Barlow and Hersen (1984) and Kazdin (lYX2) and have been illustrated for exposure treatment of PTSD by Mueser, Yarnold. and Foy (1991). among others. The case reports published on the efficacy of EMD, however, do not take advantage of the variety of design options available to clinical investigators interested in single case research. Consequently, the case studies on EMD contribute little knowledge about the efficacy of this approach. The lack of diagnostic information about patients receiving EMD does not challenge the validity of the intervention itself. but it leaves open the question of
Eye
Movement
the nature of the patient population that has received treatment. Despite the lack of scientifically adequate support for EMD, strong claims have been made as to its efficacy. Shapiro (1989b) asserts that “the evidence clearly indicates that a single session of the EMD procedure is effective in desensitizing memories of traumatic incidents and changing the subjects’ cognitive assessments of their individual situations,” and “it is apparent that the EMD procedure is extremely effective in desensitizing traumatic memories characteristic of PTSD and eliminating attendant complaints” (Shapiro, 1989a). Similarly, Solomon (1991) has described it as “a powerful tool that rapidly and effectively reduces the emotional impact of traumatic or anxiety evoking situations.” Lipke (1991) has stated that it is “by far the most effective and efficient treatment we have ever used with dissociative episodes, intrusive memories, and nightmares with Vietnam combat veterans.” Furthermore, the technique has recently been promoted as a treatment for other problems, such as anxiety disorders other than PTSD. personality disorders, multiple personality and other dissociative disorders, and the problems of adult children of alcoholics. Dr. Shapiro has recently renamed the procedure “eye-movement desensitization and reprocessing (EMDR)” to subsume additional procedures (which indirectly reinforces some of our concerns). Training opportunities in EMDR have become widely available in the U.S.A., Israel, Korea, Canada, El Salvador, Germany, Australia, Nicaragua, and Guatemala. Dr. Shapiro has developed a series of workshop programs to train and formally “certify” licensed mental health professionals in the technique. Participants in an initial twoday “Level I Basic Training” workshop are introduced to the EMDR technique. Level I graduates are encouraged to attend a subsequent two-day Level II workshop in order to obtain “a full understanding of the therapeutic utilization and myriad applications of EMDR” (EMDR Newsletter, 1991). Those who com-
Desensitization
173
plete the Level II workshop are awarded a “Certificate of Completion,” indicating their “competence” to use EMDR. Clinicians who attend the workshops are required to sign a statement that they will not train others in the method or even allow others to view printed materials distributed in the programs (see also Shapiro, 1991, for a cautionary statement about the use of EMDR by non-trained clinicians). Whereas this procedure is justified to maintain “quality control,” such a restriction of information runs counter to the principle of the open and free exchange of ideas among scientists and professionals. EMDR is also being promoted through a variety of other channels. The EMDK Network Newsletter is available to clinicians at a cost of $50 per year. Plans for a computer bulletin board arc currently under way. Presentations on EMDR have been made at professional meetings, including the Association for the Advancement of Behavior Therapy (AABT) and the American Psychological Society. Interest in both research and clinical applications of EMDR is reflected in the formation of special study groups throughout the United States. The widespread dissemination of EMDR appears premature in view of the lack of scientifically adequate support for the technique. Historically. behavior therapists have required such support as a condition for the adoption of clinical strategies, while recognizing that the exigencies of clinical practice dictate that the competent clinician must sometimes use unproven methods, and that clinical innovation is necessary for the field to progress. Ultimately. the clinician must deal with the issue of how to select treatment techniques with the highest probability of success. We propose that the most judicious strategy for making this decision is first to select techniques supported by rigorously conducted clinical research (when such techniques are available), and second to try innovative strategies when more demonstrated methods are unsuccessful
JAMES
174
D. HERBERT
or meet with limited success. In the case of PTSD, imaginal exposure (flooding) and stress inoculation training have been demonstrated to have a beneficial and durable impact on objective assessments of symptomatology (Keane, Fairbank, Caddell, & Zimmering, 1989; Cooper & Clum, 1989; Foa, Rothbaum, Riggs, & Murdock, 1991). Not every patient with PTSD responds to imaginal exposure treatment or stress inoculation training (e.g., Mueser et al., 1991). However, we believe that the strong empirical support for these interventions, in contrast to EMDR, should make them the treatments of choice for this and similar disorders (e.g., “traumatic memories”). Until the results bf more methodologically sound studies are available, we recommend that clinicians approach the use of EMD with due reserve. 1* Acknoi&dgemerrrs - Gratitude is exprcsscd to Alan S. Bellack and Edna B. Foa for their helpful comments on an earlier draft of this article.
and
KIM T. MUESER
Foa. E. B.. Rothbaum. B. O., Riggs, D. S., & Murdock, T. B. (1991). Treatment of posttraumatic stress disorder in rape victims: A comparison between cognitivebehavioral procedures and counseling. Jourt~al of‘ Consuiting
Kazdin, Methods
and’ Clinical
Psychology, 59,715-723. Sin&case research desi,w.c: forclinical ;nd applied settings. New York:
A.
E.
(1082).
Oxford University Press. Keane. 1‘. M., Fairbank. J. A., Caddell, J. M.. & Zimering, R. T. (IYSY). Implosive (flooding) therapy reduces symptoms of PTSD in Vietnam combat veterans. Behavior Therapy, 20, 245-260. Lipke. H. (IYYl. October). Cited in Eve Movement Desensirizaliorz urld Reprocessing IW-IW.? trainirlg schedule. Palo Alto, CA. Mental
Institute. Marquis, J. N. (1991). A report on seventy-eight cases treated by eye movement desensitization. Jownul- oj Behavior Therapy and Experimental Psychiatry, 22, l87192. Mueser. K. T., Yarnold, P. R.. & Foy, 0. W. (IYYI). Statistical analysis for single-case designs: evaluating outcome of imaginal exposure treatment of chronic PTSD. Behavior Modificariotz. 15. 134-155. Puk. G. (IYYI). Treating traumatic memories: a case report on the eye movement desensitization procedure. Journal of Behavior Therapy und Esperimentcrl P.svchiairv. -7.2. 140-151. Shapiro. F. (IYXYn). Eye movement dcscnsitization: A new treatment for post-traumatic stress disorder. Jourmrl of Behu\lior 20. 21 I-217.
D.
e.rperimer~fal
H..
&
Hcrscn.
desi,qu
(second
M.
Therrrpy
and
Esperimcwrtrl
P.swhrrrlry.
Shapiro, F. (1YXYh). Efficacv of the eve movement desensitization procedure in the treatment of traumatic memories. Journal of Trcrumatic Slress. 2. 190-223. Solomon, R. (IYYl. October). Cited in Eye Movemerrr
References Barlow.
ncrliorwl
Research
Sing/e cuse New York: Perga-
(1984).
ediliotl).
mon Press. Cooper, N. A.. & Glum, G. A. (IYSY). lmaginal flooding as a supplementary treatment for PTSD in combat veterans: A controlled study. Behavior Therapy, 20. 381-391.
Desensi~izafion utld Reproceasing IWI-1992 trcrirlirlg schedule. Palo Alto, CA, Mental
rrcrriomtl
Research
Institute. Wolpe. J.. & Abrams, J. (IYYI). Post-traumatic stress disorder overcome by eye-movement desensitization: A case report. Journal q/ Behavior Therapy tmd E.rperimenial
Psvchiatry.
22,
3Y-43.
