EMDR, CBT and emotion (part 1)

The key issue seems to be whether EMDR is something new and better or whether it is simply repackaged CBT.

A few days ago I asked Brian to define CBT. I did that because I think that’s an issue underlying much of the debate about EMDR that’s going on here and elsewhere. That point needs to be clarified because it’s at the heart of his concern. If EMDR is just repackaged CBT, the “hoopla” surrounding it would indeed be unwarranted. Shapiro would not be selling snake oil- she would be selling something that works, but which is commonly available by a different name (renamed aspirin would be a good comparison). Placebo response (the tendency to respond positively to treatment because one expects it to work), is always a legitimate question in studies where a treatment group has been compared to a no-treatment control group. However, there are several studies in which EMDR outperformed another treatment like counseling or relaxation. So I think the placebo argument is off the point. The real question is whether EMDR works because it’s really just CBT.
So what is CBT?The simplest definition is that it is a group of procedures based on cognitive-behavioral theories, that we lump these procedures under one heading not because they look alike, but because they are consistent with that theory. On the face of it, EMDR certainly resembles some of these treatments.
Shapiro thought she was seeing something else, though. One of the things she observed while she was developing EMDR was that people’s anxiety seemed to be eliminated more quickly than would be predicted from the cognitive-behavioral model. One of the central tenets of that theory was that people’s anxiety could be eliminated only by repeated prolonged exposure to the things they feared (hence some of the suggestions in one of Brian G’s first posts that therapy should include exposure to avoided situations and homework- the more exposure, the better, and his skepticism about anything that claimed to work faster. Very reasonable questions from a CBT viewpoint). She also thought that the eye movements were the thing that “accelerated” anxiety reduction and led to faster change.
The researchers who approached her idea about eye movements did it in a pretty logical way. They ran studies in which they compared groups of people getting EMDR with and without the eye movements. And in most cases, they didn’t find any differences. This led some people (prematurely, in my opinion), so conclude that EMDR is just good old-fashioned CBT, which works by means of exposure.
I will certainly acknowledge the possibility that they could be right, but here’s why I think it’s premature:
1. If you compare 2 procedures and they get similar results, it’s easy to conclude that they work by means of the same mechanism. There are several PTSD studies published recently showing cognitive therapy and exposure have similar results, even though the procedures don’t look alike at all. They may not use the same mechanisms but you can’t tell it from the end result.
2. The group studies which have tried to answer the question of whether the eye movements contribute anything to EMDR’s effectiveness haven’t really been designed well enough to answer the question. They have had small groups and brief treatment trials. The problem with that is that small sample sizes reduce the power of the statistics to identify group differences. Now you add to that the fact that some of these studies (not all) have been done with college undergraduates rather than real clients, and that some of the problems which were being treated were test anxiety and public speaking phobia- real problems, granted, but ones which are unlikely to generate the same levels of impairment found with Shapiro’s original PTSD subjects, and you’re likely to get the kind of discrepancy Brian’s been concerned with. Not a difference in the researcher’s bias or motivation, a difference in research design.

Replies:

Re: EMDR, CBT and emotion (part 1), by Don, 2/25/00 Re: EMDR, CBT and emotion (part 1), by Shapiro, 2/25/00

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