EMDR FORUM ARCHIVE, 2000
Re:Maxfield & Hyer meta-analysis: A few questions
Louise Maxfield · 11/03/02 at 2:19 PM ET
I hope you are not making the cognitive error of assuming that all persons who speak positively about EMDR ascribe to the same set of beliefs and behaviors. As far as I am concerned, treatment fidelity is simply a matter of internal validity. In our meta-analysis, we found a positive correlation between ratings of adequate fidelity and effect size. However, as I have said elsewhere, assessment of adequate fidelity may simply be a marker that the researchers attended to methodological rigor, and that rigor is the more critical factor. Nevertheless, studies with assessed adequate fidelity had significantly larger effects. With regard to robustness of treatment, it appears that EMDR effects may be susceptible to the manner in which the treatment is applied. I am aware that claims of poor fidelity have been used to “explain” “poor” findings in certain studies. However, I do not have enough information to have any opinion about this. Regarding exposure therapy: I was one of the investigators in, and am an author of the Taylor PTSD study. So I know first-hand how helpful and efficacious exposure therapy is. I agree with your conclusion from the research that in vivo exposure is probably an important treatment ingredient; certainly homework compliance has been found to be an important contributor to treatment outcome. It is however interesting that in the Marks study, the cognitive therapy group (without in vivo homework) did just as well as the exposure group (with many hours of homework). Similar findings were also reported by Resick et al. Marks asserts that the effect of cognitive restructuring cannot be explained by exposure, and that there must be a different mechanism. I don’t think we can assume that exposure is the mechanism underlying all successful PTSD treatment. You mention Foa’s research showing that high anxiety during initial sessions predicts better outcome in exposure therapy. One thing I find interesting is that in EMDR, the distress level (as measured by SUDS) usually drops quite rapidly during the session (e.g., Rogers et al., 1999). This suggests that there may be a different type of in-session-process. In session anxiety is one of the treatment variables that I would like to see studied in future research comparisons of EMDR and exposure therapy.
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