EMDR FORUM ARCHIVE, 2000
Re: Comments for Ulrich
Cahill · 02/07/03 at 9:00 PM ET
Ulrich: I’d like to make a few comments that address issues raised in both of your recent posts. First, you describe a video clip that Edna shows in training people to use exposure therapy. The tape to which you refer is from an episode of Dateline that aired back in the early to mid 1990’s. In the video, the therapist touches the patient during a difficult exposure specifically to help reduce the patient’s level of engagement. Part of Edna’s theory is that there is an optimal level of arousal for exposure, similar to the Yerkes-Doddson curve. In the therapists’ opinion, the patient had exceeded this optimal level and intervened to reduce it back into the optimal range. While this, and other similar titration techniques are well within the protocol that we use. However, we don’t routinely use these techniques, but apply them on an “as needed” basis. Clinically speaking, it seems that this kind of “over-engagement” (the term we use for the phenomenon demonstrated in the video) is a problem in a minority of cases. Thus, we feel no need to use such techniques with everyone. Again, I’m just describing how we use the protocol. I can’t make any data-based statements to say we know this is optimal. However, we can say that we know this approach works. Next, you draw a parallel between our occasional use of such techniques with the routine use of eye movements in EMDR. “EMDR contains sensory stimulation in its standard protocol…yes, the EMDR protocol can work without dual attention stimulation. However, in other cases, the dual attention stimulation seems critical to obtain a treatment effect. By being part of a standard protocol, it certainly it is less ambiguous for observers, and in some cases I suspect for the client.” While, it may be “less ambiguous” by having such procedures in the standard protocol, I once again call attention to the fact that none of the dismantling studies have demonstrated an effect of eye movements on outcome. Thus, even if eye movements help SOME subjects in the way we are discussing, there can’t be that many people requiring this additional intervention, else you would be able to see the effect in the overall data. In other words, even if the intervention is effective, it’s routine use is not necessary. Now, onto the belief that dissociation is problematic for exposure therapy. Yes, although it is true that Edna cautions about this, the fact is this is a clinical judgement. There are very little data. However, there are some recently published data that begin to address this. You made mention of the Cloitre et al. (2002) study. This study evaluated a treatment that started with training in DBT skills to regulate affect and foster a therapeutic relationship with the therapist, followed by imaginal exposure therapy. The subjects in this study were women with PTSD as the result of abuse in childhood. An important exclusion criteria was that participants could not meet criteria for Borderline Personality Disorder. I’m not quite sure what makes you describe this sample as “complex PTSD,” in part because the idea of complex PTSD is a clinical concept and has no widely accepted operational definition, at least as far as I’m aware. Be that as it may, the comparison group in this study was a waitlist group, not an exposure therapy condition without the prior DBT training. Consequently, the results of this study cannot inform us as to whether or not the DBT component was necessary. We can only say that the study showed the package worked. We still don’t know how important DBT was to the overall outcomes. I will, however, point out an interesting finding that actually questions the whole rationale for pretreatment with DBT. If you look at the results for the measures of dissociation (DISS) and alexithymia (TAS-20) used in this study, the results are not consistent with what you would expect. In the introduction, Cloitre et al. state the following: “Rather than reject the use of exposure and its potential long-term benefits, it was proposed that women with CA PTSD could benefit from exposure if they were provided with and learned skills to reduce trauma-related characteristics associated with poor outcome” (p. 1068). Thus, the logic of this treatment predicts that DBT should produce changes in measures of affect expression and regulation, and inherently assumes that exposure therapy won’t affect these measures. Now look at the results for the DISS and TAS-20, two of the four measures used to assess the effects of DBT: the degree of improvement on each of these measures was larger following exposure that it was following DBT. For example, on the DISS, there was a non-significant change from 26 to 20 after 8 weeks of DBT. Then the score significantly dropped from 20 to 9 after 4 weeks of exposure therapy. The same thing is true for the TAS-20: there was a non-significant drop from 56 to 52 after 8 weeks of DBT, but the dropped significantly from 52 to 43 after 4 weeks of exposure therapy. These data raise the distinct possibility that, contrary to current popular belief, exposure therapy may be a better treatment for dissociation and alexithymia than DBT. If that turns out to be true, then it makes no sense to withhold treatment with exposure therapy because of dissociation. Turning briefly to EMDR, despite all the clinical talk about EMDR breaking down dissociative barriers, I’m not aware of a single study in which this has been measured, much less demonstrated. You make a bold prediction about differential effects of endorphine blockade on outcome for exposure therapy and EMDR. If your pattern of results could in fact be demonstrated in the context of a single study (i.e., that naltrexone interfered with the efficacy of exposure therapy but facilitate EMDR), this would indeed be an impressive finding, clearly demonstrating that different mechanisms were involved. However, let’s be clear that this is still just a thought experiment: It has not yet been done, much less replicated. I personally doubt the study would produce the predicted results, but I am going on record that, if you can show me the data, I will alter my views. Lastly, in regard to your contention that EMDR is easier for the therapist to tolerate than exposure therapy, that may be true. I’m not aware of any data. However, if you are motivated by not having to listen to the content of your patient’s traumatic experiences, then why not use anxiety management or cognitive restructuring. These two treatments also work for PTSD and require no discussion of the trauma at all. Why not use them instead?
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