EMDR FORUM ARCHIVE, 2000
Re:Maxfield & Hyer meta-analysis: A few questions
Cahill · 11/03/02 at 11:43 ET
Louise: Again, I'm not disagreeing with the methodological position you advanced (i.e., internal validity). I actually endorse it. What I'm raising is what appears to me to be a double standard in how this gets implemented. So, when Grant publishes a study that has (IMHO) minor deviations from the standard protocol, but the results of the study show CBT to be better, we hear complaints about violaiton of treatment fidelity. However, when a known proponent of EMDR changes the technique, the working assumption appears to be that such changes inevitably improve the technique. Such examples are not limited to Shapiro's change of EMD to EMDR and Sandra's Dissociation protocol. Consider the EMDR phobia protocol. A distinction is made between simple phobias and process phobias. Now nevermind the fact that there is no research to validate this distinction, researchers that attempted to apply the simple phobia protocol to the treatment of spider phobias, which Shapiro (1995) explicitly uses as an example of a simple phobia. Yet, Add De Jongh et al. (1999) criticize the researchers for not applying the process phobia protocol. In a recent book, Shapiro co-authored a chapter with Leeds (I think) in which the emphasis was on resource installation. There is no data to suggest that this new emphasis improves treatment. Yet, if someone were to now use the standard protocol in research, they are open to the charge that they are not using the most updated version of EMDR. There is a second way in which I think the treatment fidelity issue gets misused is when people suggest that, on the one hand, EMDR is so sensative to changes in the protocol that things like asking a person to provide a VoC of the negative cognition at the beginning of the session could reasonably be thought to significantly undermine the therapy, but to also argue that EMDR is so chock full of effective ingredients that it is entirely possible that you can eliminate a procedure such as therapist directed eye movements that at one time was so central the therapy that Shapiro called it the "crucial" component of EMDR and it forms the beginning two words of the therapies name without any demonstrable effect (as of yet, anyway). Again, either the therapy is robust or not. But it appears that it is robust or not depending on whether the writer needs to explain why a treatment failed when it otherwise should have worked, or to explain why a treatment worked when it otherwise should not have. Now, regarding your remarks about Edna commenting that the current PE protocol is different from the earlier one, I too have heard her make such remarks. My position is that her remarks may or may not be true, but the reality is we don't know. We can say that the effects sizes for PE have in fact increased over the three studies that have been completed through the Center for the Treatment and Study of Anxiety (CTSA). We can also say that the PE manual has certainly chaged over the years. It went from a small handout to a pretty thick book. The larger effect sizes could reflect greater experience with the technique, but it also could reflect changes in subject pool, or a number of other things. Nobody can say for certain what the cause for this effect is. I personally don't find such speculation to be of much use unless it leads to testable hypotheses that will be translated into research. On a related topic are the various exposure therapy protocols, each of which has been seperately validated but not directly compared (e.g., Foa et al., Tarrier et al., Marks et al., Blanchard et al.). While we have no evidence that one protocol per se is better than another, we can say that there is evidence for a specific contribution of in vivo exposure to reducing behavioral avoidance as compared to imaginal exposure (Richards et al., 1994). This is consistent with other research on exposure therapy for other anxiety disorders, such as agoraphobia and phobias. We can say that level of anxiety during early exposure sessions correlates positively with outcome (more anxiety during exposure, better outcome) in PTSD, consistent with research in other areas of anxiety (again, e.g., OCD). We can say that habituation across exposure sessions is associated with better outcome in exposure for PTSD, as it is with other anxiety disorders. There are now a couple of studies showing that, while cognitive therapy and stress inoculation traingin (SIT) provide similar outcomes as exposure therapy, combining treatments does not result in better outcome. Exposure therapy plus SIT (Foa et al., 1999) and exposure therapy plus cognitive therapy (Marks et al., 1998; also a study by Ost, but I can't recal the first author's name) do not yield better outcome than exposure alone. Thus, we see some general principles evolving that are independent of the specific version of exposure therapy. When you have a robust treatment like exposure therapy, you don't have to worry as much about details. For example, Edna's PE manual has specific analogies to help educate patients about how PE works. But therapists routinely use variations on these analogies. Edna herself can come up with new one's at the drop of a hat. The goal is not to parrot the words from some manual, but to educate the patient in such a way that doing exposure makes sense to the patient so that he or she will be willing to undergo the treatment. Although there are different exposure protocols, and even though there may have been changes across iterations of any particular protocol (e.g., Edna's), we all agree that we are doing exposure, and we all agree on certain basic boundary conditions for doing exposure that is "good enough." My own view is that we are implementing empirically known principles of behavior change, not administering a particular technique. So, to me it's not surprising that no-one has changed the name of their specific protocol just because details have changed nor has anyone trademarked the name of their exposure protocol. One of the real problems we have in psychotherapy is the proliferation of "name-brand" therapies that may be nothing more than repackaged old ideas with some new twist that is assumed to be of significance but lacks empirical support. What is going to stop us from developing "Pink Asprin" and Purple Hat" therapy? (For those not familiar to these references: Pink Asprin therapy would involve coloring white asprin pink, doing a study to show that it relieves headaches relative to a placebo, and then asserting that the pink coloring is what made it so effective; Purple Hat therapy would involve conduting an empirically supported treatment such as in vivo exposure for simple phobias while wearing a purple, conduting a study to show that purple hat therapy works relative to waitlist, and then asserting that one must purchase my purple hats or they are doing the technique wrong.)
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