The following is an e-interview by Joan Cook and James Coyne. The two influential psychologists discuss the dissemination of EMDR, what it means for the proponents of other therapeutic approaches, and what their experience was in publishing a paper on these topics.
You recently published an article in Professional Psychology that by its title alone is likely to attract controversy. What was your purpose in conducting the study and what were your most interesting results?
Cook: The title, “Comparative Case Study of Diffusion of Eye Movement Desensitization and Reprocessing in Two Clinical Settings: Empirically Supported Treatment Status Is Not Enough,” was intended to be a bit provocative. Interested readers of Psychotherapy Brown Bag can get a free PDF by dropping me an email at Joan.Cook@yale.edu. We were interested in the apparent popularity of EMDR, at least among non-academic psychologists and other practitioners, and how it seemed to take hold in some settings, while being thoroughly rejected in others. We chose two VA medical settings, one in which it had taken hold, and one in which it did not, despite free training being offered. We were certainly aware of the controversies surrounding EMDR, but chose to take a neutral stance in an effort to grasp whatever lessons that could be learned in terms of effective dissemination and implementation of a therapy approach with sustained use. Hopefully regardless of their attitudes to EMDR, readers can learn something about the poorly understood topic of how one obtains sustained use of the psychotherapy by frontline clinicians.
Perhaps our most interesting findings were clinicians adopting treatments because they personally perceived the positive effects of the therapy in their own lives, what we call “experiencing is believing,” and also that a psychotherapy being adopted in a setting can become part of that program’s deeply entrenched identity.
How do you explain the popularity of EMDR?
Cook: First, we have to be careful about the assumption that it is that popular. We have an unpublished survey of over 2,200 U.S. and Canadian non-academic psychotherapists (many of whom were master’s level social workers) who completed a web-based survey concerning their use of over 60 specific psychotherapy techniques. EMDR was one of the least frequently used practices.
I have to admit, however, when we began this study, I was sold on the popularity of EMDR and assumed it was more widely used in routine practice.
Coyne: I agree, when we started the study, I assumed that we were studying a populist phenomenon, a therapy widely adopted by front-line clinicians that had developed outside of and in the face of opposition from academia. I wanted to understand how it spread, almost virally. But in retrospect, I think I was too impressed by the antipathy of academic psychologists to EMDR to appreciate that EMDR was not actually widely practiced. In a paradoxical way, opponents of EMDR have contributed to whatever appearance of strength and popularity it has. I was certainly caught up in this illusion.
How you explain the antipathy towards EMDR?
Coyne: I think EMDR poses an interesting dilemma for advocates of evidence-based treatments, particularly academics. Strictly speaking, it meets the criteria for an evidence-based treatment. But some of the explanations that are offered for the mechanism of effect are patently absurd and there are a lot of "off label" applications that do not have a basis in best evidence. I think just the notion of a therapist sitting in front of patient and waving a finger back and forth or using tappers is tough for a lot of therapists to accept, regardless of whether it is effective treatment. Personally, I would feel ridiculous doing this.
But the interesting dilemma for advocates of evidence-based treatment, who are offended by EMDR, is how they can exclude it from being classified as being evidence-based without being inconsistent and even hypocritical. One strategy is to point out that EMDR does not have a verifiable mechanism of effect and propose this as an additional criterion. The problem is that numerous effective biomedical interventions would fail to meet this criterion and arguably, some other treatments academics want to accept as being evidence-based are at least as controversial as those who do not share a particular theoretical orientation.
I find proponents of EMDR, somewhat embarrassing to the promotion of it as evidence-based treatments with their willful violation of the tenets of evidence-based psychology in their application of EMDR to other disorders and problems well beyond the evidence of its efficacy. Treatments are not evidence-based, you know, but the application of them to particular clinical problems is. Yet, I find the gyrations of those who would exclude it hypocritical. It is certainly an interesting case study in how we evaluate evidence and the factors other than evidence that come into play.
So where do you stand on EMDR?
Coyne: I don't think I could be clearer, even if my answer is complex. It works, the explanations about why it works are annoyingly silly, and its off label applications are certainly not justified. But then again, these criticisms are applicable, in whole or part to other treatments that don’t come under attack.
Cook: I try not to get my personal opinion in the way of trying to understand why psychotherapists choose to adopt and sustain their use of various therapies. I’ve been trained in all the evidence-based treatments for PTSD and I have recently received a Stimulus Package NIMH R01 to understand the implementation of two other evidence-based treatments for PTSD, Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT), in a national rollout.
Have you encountered any flack in trying to get this paper published?
Cook: Surprisingly, this paper took three rounds of reviews and numerous rich quotes and insights had to be cut to meet paper length as well as to maintain neutrality. The reviewers clearly perceived that we were anti-EMDR folks and we are thankful to the editor for judiciously mediating between reviewers and us. It was at times quite frustrating, though. In the end, the paper was strengthened.
Do you have related follow-up projects?
Coyne: I think there's still lots be learned about the popularity of EMDR that could be applied in the dissemination of other treatments. However, I'm reluctant to get into too much controversy with the proponents of the EMDR, because I think it only serves to promote EMDR. A lot of the illusion of its widespread application comes in the conflict that is generated by people who don't like it.
Cook: As I mentioned, we have a paper under review in which we surveyed thousands of therapists as to what they do with patients. EMDR does not rank high on the list. This was a shocker to me as I had believed all the hype – EMDR’s use was quite low actually. Perhaps practitioners seek training in it but then don’t actually use it?
I'm most excited about the receipt of the stimulus package R01 to investigate factors associated with successful rollout of PE and CPT for PTSD in VA residential settings. EMDR isn't one of the treatments in this rollout, and so we don't focus on it. Jim and I will again be working together on this.
Coyne: But Joan is the PI on this exciting project. I had actually counseled against submitting the application because I believed that the odds of getting stimulus package funding were so low. The odds were miserably low, but Joan got one. I guess now I would say no one gets a grant without applying, unless it is something like a MacArthur Award.
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