Sandra

Well, the replies from Sandra and Barbara will hopefully teach me a lesson to never again complain about getting bored with the discussion on this web site. The Sandra's and Barbara's post are very different from one another: Sandra focuses on her attempts to make sense of her clinical experiences, but does nothing to challenge my epistemological position. By contrast, Barbara proposes (IMHO) a fundamentally different paradigm, essentially arguing that the assumptions and methods of modern science do not apply to the investigation of ways to alleviate human suffering. Given that these are very different responses to the issues being discussed, I am going to provide separate responses, and I will deal with Sandra's reply first.

Sandra, first of all I appreciate the compliment, although I will admit I wasn't sure if it was a compliment or an insult until I had the chance to consult my dictionary as to the meaning of "erudite". I suspect your verbal score on the GRE was in excess of 700. As you know, there is no comparable phrase in Hawaiian for "your welcome" so I'll just say that I'm glad to occasionally play the role of the gadfly. Now, with those niceties out of the way, let's turn to your comments on my position regarding the role of eye movements in EMDR…

You pose the question, "How shall I [Sandra] explain to myself that with certain DID clients, the addition of eye movements to a discussion of traumatic material causes immediate flooding and breakthrough of several channels of sensory information that was not there moments before the addition of eye movements?"

My simplest response to your question, being a very strong defender of the First Amendment and generally a Civil Libertarian in my political view, is that you may tell yourself anything at all about what you experience: Who am I to dictate to you what say or believe? Infer that your observations are the product of aliens channeling healing energy powers to your patient through your induction of eye movements, for all I care. However, your right to say and believe what you want does not mean that you are correct, nor does it mean that I can't criticize or even make fun of you for your beliefs. I too have First Amendment rights, which I may or may not chose to exercise when I hear people say things I believe are wrong or just out right stupid.

However, I doubt you meant your question in quite the light that I cast it in my initial response. More likely, the question is better cast as if it were directed to me, so the question becomes, " How do you [Shawn] explain my [Sandra's] observation that with certain DID clients, the addition of eye movements to a discussion of traumatic material causes immediate flooding and breakthrough of several channels of sensory information that was not there moments before the addition of eye movements?"

My answer to this re-phrased question is that I feel no obligation what-so-ever to offer an explanation for your observation. Recall that I am not making any positive assertions about the role of eye movements. Thus, I have no burden of proof. You, on the other hand, are making a positive claim about the role of eye movements, perhaps indirectly because you are asking a question, but the gist of your comment is that your observations have convinced you that eye movements are an active ingredient in EMDR.

The issue for me really boils down to whether you have proffered adequate evidence to meet your burden of proof. If you have not, then my position remains unchanged. If you have, then I am forced to modify my conclusion. In other words, I am not in the game of trying to maintain my beliefs no matter what. For example, I'm not going to waste my time trying to think of an explanation for your observations that allows me to continue believing that eye movements have not yet been proven to have an effect on treatment outcome. Rather, if your burden of proof has been met, then I'm going to conclude that eye movements do have an effect on treatment outcome.

Accordingly, instead of giving you some "just so" story to explain your observations, let's turn to an evaluation of whether your observations meet the burden of proof.

1. You make reference to an "immediate flooding and breakthrough of several channels of sensory information."

I beg your forgiveness, but I am a pretty dull, unimaginative, behaviorist. What exactly do you mean by this description? What are the behaviors that constitute or indicate the presence of an immediate flooding of sensory information or a breakthrough of several channels of sensory information? Can this be measured reliably? Is it a valid indicator of treatment outcome?

2. My understanding of the procedure involved in your observations is that you administered one intervention, call it A, and then, when failed to observe the immediate flooding and breakthrough of several channels of sensory information, you applied a modified intervention, call it A' (pronounced "A prime"). Assuming I have the procedures correct...

How do you know that the observed flooding and breakthrough in sensory information was an immediate response to A' and not a delayed response to A? How do you know that the observed flooding and breakthrough in sensory information was not the result of the combination of A followed by A'? How do you know that the observed flooding and breakthrough in sensory information was not the result of some other, but as of yet not identified, factor in your clinical activities? What steps did you take to make sure that the only difference between A and A' is that you did not induced eye movements in A' but you did induce them in A'.

Within scientific psychology, we have some pretty well agreed upon procedures to address these various challenges to internal validity. And based on several of your previous posts, I know that you know what these are. But for those not as familiar with standard research design, they include such things as:

Operational definitions of independent, dependent, and process variables that are assessed using valid and reliable measurement instruments or procedures; the use of multiple subjects and large enough sample sizes to insure reasonable power to detect differences; the use of control conditions that include all elements of the proposed treatment except the specific aspect of interest; random assignment of subjects to experimental or control treatments or, if using a completely within group design, proper counter-balancing of treatment components control for order effects; and the use of evaluators who are blind to subject conditions; the application of appropriate descriptive and inferential statistical methods to the data, and even then waiting for independent replication before getting too excited (remember, even results that would only occur by chance 5% of the time will still happen by chance 5% of the time!).

Now, either your observations meet these standards or they do not. If they meet these standards, then PLEASE submit them for publication IMMEDIATELY. At present there are no empirically validated treatments for DID. Having one would be a great contribution to the field. However, if your observations do not meet these standards, then please explain why you think that you, me, or anyone else should be convinced that they establish a role of eye movements in the treatment of DID with EMDR?

To illustrate my point, let me tell you a story. One of my faculty during graduate school likes to tell about the time when he was visiting a large state-run psychiatric institution. He had (and still has as far as I know) a reputation of being a staunch behaviorist who did not (and probably still does not) believe that diagnosis of DID (or MPD as the diagnosis was called back then) actually captured any aspect of reality. The psychologist who was giving my faculty the tour wanted to convince him about the reality of DID and therefore was eager to introduce him to a patient that carried the diagnosis. Apparently, the patient displayed a number of different personalities which switched so frequently that the staff had learned to inquire as to who she was at any given time before interacting with her in any meaningful way.

My faculty observed how the staff interacted with her, and hypothesized that staff attention was in fact serving to reinforce her behavior and that, rather than having multiple personalities, she simply learned to behave that way in order to get meaningful interactions with the staff. (Parenthetical note: I'm sure this kind of analysis of DID may offend some readers of this forum and seem to trivialize the conditions that cause the disturbance labeled as DID. However, you may be more sympathetic to this position if you were to work in a chronic ward at a psychiatric unit. Patients on these units are usually heavily medicated and under-stimulated. At the same time, these places are chronically under-staffed and the staff they do have or are overworked and underpaid. One of the most reliable ways to get attention from the staff is to behave in an odd or violent manner. If you are quiet and pleasant, you get ignored.) Continuing with the story...The faculty decided to test his theory. When he met the patient, he basically told her to knock it off, and that he would be happy to chat with her, but only when behaved as if she were the primary person. The faculty reports that the patient immediately shifted to the primary personality and, even though she continued to be other people when interacting with other staff (who continued to interact with the patient as they always had), that every time after that initial meeting, the patient always interacted with him as if she were the primary personality.

Now, would you accept this as a valid demonstration of an effective treatment for DID? If not, why not? If clinical vignettes, such as the one posed in your post, can be used to prove an hypothesis, then why do your clinical vignettes trump other people's vignettes if they have had different experiences?

My own position is that neither yours nor my faculties clinical experiences proves anything. At present, we have no convincing evidence that EMDR (with or without eye movements) is efficacious in treating DID and we have no evidence that telling people to "knock it off" is efficacious in treating DID. And, to bring it back to what started this thread, we have no convincing evidence that eye movements contribute to the outcome of treatment for PTSD with EMDR.

Replies:

Re:Sandra, by Sandra Paulsen Inobe, PhD, 01/18/03

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