Comments on Eye movement desensitization and reprocessing (EMDR): What is it and does it work?

Michael and Joye Anestis commented on 'Eye movement desensitization and reprocessing (EMDR): What is it and does it work?'

2009-10-22T13:33:50Z

I'm not sure what you mean when you refer to me not being able to find research less than ten years old. Even just a quick read of the article will reveal that the final section is devoted to the fact that the special issue reviewed here is, in fact, from 1999 and that more research exists, but that covering all of it in a single article would be unrealistic. I also pointed readers towards the APA Division 12 website, which summarizes more recent research for EMDR in general and how it applies to various diagnoses. I found plenty of literature more recent than that, but I base my choice of reviews on quality, not age, as age has no impact on methodology and conclusions.

That being said, I fully intend to follow-up on this article, but I have delayed that plan because, in all honesty, every single interaction I have had with EMDR proponents has been aversive. I have received stunningly offensive and unprofessional emails (as have peers who are entirely unrelated to PBB - I suppose in an attempt to somehow get me in trouble for questioning the empirical status of particular aspects of EMDR) and other forms of communication that have left me less interested in discussing this matter. I'm certain there are many EMDR proponents who would never behave in that way, but sadly none of them have reached out to me to discuss this in a civil manner, so the conversation has stalled. It would be wonderful if a fruitful exchange of ideas occurred here for readers to consult in order to make more informed choices.

All that being said, I read the article you referenced and would like to respond to its impact on my article. Before doing that, however, let me again clarify the conclusions of what I wrote:

- There is very strong evidence that EMDR produces impressive results in the treatment of PTSD
- There is weak evidence that eye movements add anything to treatment outcome

The article you referenced made an effort to clarify that second point. It had many strengths, including sophisticated statistical analyses and some strong methodology. It also had several fatal flaws that prevent anyone from reasonably concluding that it indicates eye movements are the mechanism of change in EMDR for PTSD. The flaws are as follows:

- The sample was comprised of undergraduates, none of whom met criteria for PTSD or exhibited elevations on symptom measures of PTSD (or any other mental illness)
- Any participant whose recollection of a traumatic experience caused him or her to experience more than mild to moderate anxiety (SUDs equal to or greater than 6) was excluded from the analyses

These first two flaws are vital. Unless individuals are actually being treated for PTSD, how can we discuss the mechanisms of change in the treatment of that disorder? Additionally, because exposure requires that clients experience anxiety repeatedly until they habituate and no longer respond in that manner to the particular cue, this study was incapable of determining whether eye movements are the mechanism of change rather than exposure. If you are not allowed to experience significant anxiety, exposure can not work, so the study handicapped exposure in order to demonstrate that eye movements make important contributions even when controlling for the effects of exposure. In other words, this study seemed to examine whether eye movements are more pivotal than exposure for PTSD by removing the possibility of exposure and not treating individuals with PTSD. That's a problem.

- The only outcome that eye movements appeared to impact was SUDs (and even that conclusion is open to question given that individuals who had highly elevated SUDs levels were not allowed to participate in the study). Vividness, which the introduction described as a critical point of intervention in this treatment, was unaffected by eye movements. Additionally, the main effect of eye movements was non-significant for both outcomes. It was the interaction of eye movements with particular forms of therapist instructions that impacted SUDs. In other words, eye movements themselves were not directly predictive of differential outcomes and, because of the dearth of covariates used in the analyses and the impossibility of exposure working in this sample, the possibility of a third variable accounting for this outcome is larger than normal.

PBB advocates for an accurate understanding of the empirical evidence supporting various therapeutic approaches. We are not anti-EMDR or any other approach. We simply do not approve of researchers or clinicians making claims that are not substantiated by empirical evidence. If this study were done in a sample of individuals who met criteria for PTSD and individuals who experienced clinically relevant levels of anxiety were not excluded, the results would be more interesting. As it stands, however, this study does nothing except contribute to the equivocal nature of the results on this topic and, in all honesty, it might not even do that.

I do truly appreciate you referencing a specific study that attempted to address this important question and I will gladly read and review others. Your comment even has me considering finally doing an EMDR follow-up (perhaps discussing the article you suggested), but we'll see about that. There are many topics I can cover here that are substantially less likely to result in people sending me offensive and childish notes.

- Mike Anestis

Steven Thomas commented on 'Eye movement desensitization and reprocessing (EMDR): What is it and does it work?'

2009-10-21T21:37:15Z

It's too bad you couldn't find any research that was less than ten years old, because there's a ton of it and skepticism is certainly the order of the day until positive data accumulates. Here's just one instance supporting the efficacy of bilateral eye movement: "Effects of eye movement versus therapist instructions on the processing of distressing memories", Journal of Anxiety Disorders, Volume 22, Issue 5, June 2008, Pages 801-808.

Mike Anestis commented on 'Eye movement desensitization and reprocessing (EMDR): What is it and does it work?'

2009-06-19T22:26:52Z

Kelly -

I like this point a LOT. You and I spent a good amount of time telling clients about radical acceptance and doing what works during our DBT skills training days, so we might benefit from applying that lesson to our own careers.

I agree with you that, intellectually, the idea of adding bells and whistles to treatments that already work is unappealing. At the same time, if we can add a component that does not add significant cost and does not decrease the efficacy and effectiveness of the treatment approach while vastly increasing interest in the treatment, that seems like a strong business decision. Ultimately, the point of all this is to provide effective care for the greatest number of people possible. If some sort of novel component can serve to vastly extend the reach of the treatment, that's a lot of value.

Thomas has told us that DBT, to some extent, features components that are aimed mostly at marketing and appealing to clients on a more superficial level. Maybe more ESTs need to take that approach.

Kelly Schmeelk commented on 'Eye movement desensitization and reprocessing (EMDR): What is it and does it work?'

2009-06-19T19:22:02Z

I think this is a really great, helpful review of the literature, Mike. The popularity of EMDR and other, somewhat odd therapies has always made me wonder if the inclusion of gimmicky components increases the appeal of a particular therapy. Is it easier to accept a therapy with a non-intuitive component (like lateral eye movements) vs. typical therapies (e.g., CBT)? Sometimes I feel that CBT falls prey to the "why pay someone to do what my best friend/mother/spouse does?" argument, however faulty that logic is.

Although I am inclined to be opposed to components that do not add to the overall efficacy of a therapy even if it's not iatrogenic, because it seems disingenuous, it occurs to me that taking into account the business aspects of making a particular therapy appealing to the masses may involve something a little flashier than talking and homework. Not that I have a problem with that setup!

Certainly this isn't the only way to make ESTs appealing and accessible to the broader public, and I think adding "flash" would require a continued focus on efficacy and accountability rather than just mass appeal.

Just a few thoughts...