Re:Point/Counterpoint Article Posted Online

Hi Ricky:

I have to admit, I don't quite understand where your first point is coming from. Let's trace this thread back, OK. Sandra posted an address where to find an article I wrote a couple of years ago in which I summarized research on EMDR, including outcome and dismantling studies. Sandra then posted a comment from Sue Rogers that the dismantling studies I cited were flawed.

Now, a few things. First, if you read my original article, you will see that I note the concerns of EMDR proponents, I make reference to the fidelity issue, and even site one of your papers. So, I think that I was quite balanced on the issue.

Second, in my paper and my post about my paper, I make the point that even if we discount these studies for various methodological reasons, we end up with the same conclusion. To wit: there is no convincing evidence at this point that eye movements add to treatment outcome. Moreover, the burden of proof rests with those who continue to claim that eye movements (or bilateral stimulation or dual attention) are an active ingredient. If you know of some other dismantling studies that meet the various criteria that have been set out (in one of the posts above Sandra summarizes quite heavily from Shapiro's book laying out her views on this), then please enlighten me. If not, all I ask is that you acknowledge that the burden of proof has not yet been met.

So, given this history, I really don't understand your comment about treatment fidelity. It is at best a side issue here. I'm trying to talk about burden of proof.

However, because you have raised the issue of treatment fidelity, I will remind you that in the Pitman et al. (1996) study, treatment fidelity correlated with treatment outcome in both the EMDR condition AND the eyes fixed condition. Importantly, there were no differences in outcome. Although these data support the contention that treatment fidelity is important, it had nothing to do with eye movements.

You question why all this emphasis on dismantling studies: Shouldn't we first determine which treatment is better before worrying about active ingredients? Personally, I think that horse races and dismatling studies answer different questions and there is no reason to pursue one over the other. Some researchers are very pragmatic and just want to know which is the best mouse trap. Other researchers want to know how both the good and the mediocre mouse traps work. Comparative outcomes studies won't tell us this. Consider the research indicating that outcome for exposure therapy and stress inoculation training produce similar outcome. What does this tell us about how each of the treatments work? Do they work through different mechanisms to achieve the same general outcome? Do they work through different mechanisms? If so, what are those mechanisms? How do we know this? A simple horse race won't answer these questions. Both types of research advance our knowledge, but in different ways.

Now in regard to your comment about eye movements being red herrings. I disagree. You (in earlier posts) continue to maintain that there is something unique about EMDR. Other theorists continue to generate speculation as to the role of eye movements (or bilateral stimuli, or dual attention). For example, in recent Journal of Clinical Psychology special issue edited by Shapiro, Robert Strickgold has a paper entitled "EMDR: A putative neurobiological mechanism of action." In the abstract, Strickgold states

"We propose that the repetitive redirecting of attention in EMDR incudes a neurobiological state, similar to REM sleep, which is optimaly configured to suppor the cortical integration of traumatic memorreis into general semantic networks. We suggest that this integration can then lead to a redcution in the strength of hippcampally mediated episodic memories of the traumatic event as well as the memoreis' associated, amygdala-dependent, negative affect."

Later, he speculates that in EMDR there is "a pattern of alternating, bilateral stimulation that forces the subject to constatntly shift her attention across the midline" (p. 70-71).

Again, Strickgold states "In summary, our model proposes that the constant reorienting of attention demandd by the alternating, bilateral visual auditory, or tactile stimuli of EMDR automatically activates brain mechanisms which facilitates this reorienting. Activation of these systems simultaneously shifts the brain into a memory processing mode similar to that of REM sleep. This REM-like state permits the integration of traumatic memories into associative cortical networks without interference from hippocampally mediated episodic recall...But EMDR can work even better than REM sleep for two specific reasons. First, unlike REM sleep, when front lobe activity is largely inhibited (Hobson et al., 1998), during the EMDR treatment the patient can choose the material to hold in mind at the start of the bilateral stimulation...Second, through careful management by the therapist, levels of anxiety and fear during EMDR treatment largely can be maintained at low levels, enhancing the ability of the bilateral stimulatin to produce the desired physiological and neurochemical shifts in the brain without interference from increased NE [norepinephrine] levels" (p. 71-72).

Boy all of this talk about brain parts, neurotransmitters, and REM sleep, I almost forgot that there is no credible evidence that eye movements or any other bilateral stimulation improve treatment outcome.

Finally, in your e-mail, you pose to alternative topics that could be persued: (1)Further discussion of treatment fidelity and the Maxfield & Hyer meta-analysis and (2) discussion of recent treatment outcome studies. Both would be great topics with which to start a new thread. Number 1 would be particularly interesting if Maxine would join the discussion, as I'd be interested in asking her about some of the various decision points they faced in conducting their meta-analysis. As I believe you pointed out in an earlier post, what you get out of a meta-analysis reflects what you put in. Number 2 is hampered a bit by the fact there are two major comparative outcome studies (by Rothbaum et al., and by Taylor et al.) that have been presented at conferences but are not yet published. I don't feel comfortable discussing the results of papers until they are published and available for general insepction.

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Re:Point/Counterpoint Article Posted Online, by Ricky Greenwald, 10/29/02

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