EMDR FORUM ARCHIVE, 2000
Re:Maxfield & Hyer meta-analysis: A few questions
Louise Maxfield · 11/02/02 at 3:06 PM ET
Hi Shawn: 1. Regarding internal validity. As I am sure you know, treatment fidelity is essential for internal validity in research studies. If the protocol that is studied is a modified version of the standardized protocol, it will be unclear if the findings are specific to the modification or if they can be generalized to the standardized protocol. In this regard, it is not particularly relevant if elements of the protocol are empirically derived. What is important for internal validity, in the testing of a specific protocol, is protocol adherence. For example, suppose I was testing the efficacy of prolonged exposure, and that, instead of following the protocol and keeping the participants focused on the traumatic incident, I repeatedly asked them to think of other related memories. I could “say” that my study tested prolonged exposure therapy, but in fact, my study would be testing a modification and the results would probably not be generalizable to standard prolonged exposure. Similarly, imagine a study investigating EMDR that, instead of following the protocol and keeping the participants focused on emerging associated material, repeatedly asked them to think of details of the traumatic incident. This study would be testing a modification of EMDR, and the results would probably not be generalizable to standard EMDR. Surely you are not suggesting that researchers can arbitrarily change elements of a standardized treatment protocol, and still claim to be applying the protocol? I would expect that you would agree that there should be rigorous adherence to protocol specifics. We may not be convinced that all elements of a protocol are essential, but surely, when a protocol is being scientifically evaluated, it should be applied in an optimal manner and include all components. 2. Regarding theoretical reasons for treatment focus. As Sandra articulately explained, there are theoretical reasons why referring the client back to the negative cognition, and taking frequent SUD ratings might reduce the efficacy of EMDR treatment. EMDR is an information processing therapy in which eye movements decrease the distress related to a traumatic incident and free association is used to elicit other memories and information. During the EMDR process, as one aspect of the memory is desensitized, other elements are elicited with free association, and then also desensitized; the desensitized memory is then integrated with more adaptive information that is also elicited through the free association process. During this process, the client’s attention is *not* brought back to the original image, negative thought, or body sensation, nor is the client repeatedly asked to focus on those elements and produce a SUD rating. The client’s attention is drawn back to the original incident solely for the purpose of eliciting more material and information. That is, the client is asked, “As you think of that incident now, what do you notice?” It is not until nothing new is elicited with free association, that the therapist takes a SUD rating to confirm that the memory has been *completely* processed. Note that the client’s attention is not brought back to the original identified aspects (image, negative thought, body sensations) because it is expected that these will have been changed in the desensitization process. In EMDR, the focus is not on the details of the original memory, but on the changes to the memory as it is processed.
3. Regarding empirical reasons for treatment focus.
As far as I am aware, there is no research specifically investigating the role of free association in information processing, or the essential elements in conducting this aspect of therapy. Research is needed to investigate this. However, it should be noted that EMDR, which uses this approach, is efficacious in the treatment of traumatic memories and trauma related disorders. I think it would be interesting to compare standardized exposure therapy, with its focus on the details of the traumatic incident, to a modification in which the focus is on other related memories and material elicited through free association.
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