Re:What is EMDR?

Ricky:

I think that the majority of your preceding post, all the comments about prepatory phases before doing EMDR, was in response to my suggestion about your proposed study in which you compare Deblinger's package with EMDR wrapped in the same "packaging" as Deblinger's package. I suggested that, given the data from the Hawaii group in which they found EMDR without all the trappings of Deblingers package, was effective, your study would be stronger if you added a regular EMDR group. And by regular, I mean just like the Hawaii group.

If I'm correct that your comments are about this suggestion, them I'm a bit puzzled. You said in part:

"There will always be some preparatory phases. These are, technically, "additional interventions." I would not run a study including a group without the preparatory stuff, it would be clinically inappropriate, unethical, and have no chance for external validity (it would not apply to the real world of clinical practice)."

A. Did the Hawaii group include prepatory interventions that are not part of the starndard 8-phase EMDR program?

1. If they included additional prepatory interventions, did the control group get this intervention? If the control group did not get the additional interventions, what reason is there to think that it was EMDR that helped these children and not the non-EMDR prepatory interventions?

2. If they did not include additional prepatory interventions, was this study "clinically inappropriate, unethical, and have no chance for external validity"? If this study was "clinically inappropriate, unethical, and have no chance for external validity," why did you previously cite it as evidence for the efficacy of EMDR? If this study was not "clinically inappropriate, unethical, and have no chance for external validity" what all of a sudden makes my suggestion that you include such a group in your study "clinically inappropriate, unethical, and have no chance for external validity"?

I would suggest that, if we don't know the value of something, that it is perfectly ethical to investigate that. In fact, it could be unethical not to investigate it. Consider the recent study by Cloitre et al., in which she treated a group of women with PTSD resulting from childhood abuse with a sequential treatment consisiting of a number of sessions of DBT (she called it STAIR) followed by a number of exposure sessions. He control group was a waitlist condition. Her results clearly demonstrated the package was effective, and it is her hypothesis that pretraining with DBT enhanced the efficacy of exposure therapy. However, her study was not designed to evaluate her hypothesis. To do so would require the inclusion of a group that received exposure therapy without pretreatment with DBT.

Now, let's say that a second study is conducted that includes three groups: waitlist, exposure alone, and DBT plus exposure. We can easily predict that active treatment will be superior to waitlist. The question is, will combination be better than exposure alone? If the answer is yes, then terrific, we now know that it makes sense to DBT first, at least for some people. If, however, the answer is no, then it would be unethical to require peeople to undergo DBT before exposure. Insisting on DBT first harms patients in at least 3 ways:
1. The combined treatment costs more. Therefore it wastes the patient's financial resources.
2. The combined treatment delays access to the important aspect of treatment. Therefore it uneccessarily extends the patient's suffering.
3. Requireing people to jump through this extra hoop before getting the real treatment may discourage people and cause them to drop out of treatment before they ever get to exposure.

Given that we know exposure without several sessions of DBT is in fact helpful, then not investigating the additional impact of pretreatment with DBT would, in my opinion, be unethical. Similarly with EMDR. We know that it works. Adding additional elements without also evaluating whether those additional elements adds to outcome could well be penny-wise and pound foolish.

The rest of your post apparently is a consession that Ironson et al. altered the EMDR protocol by adding in vivo exposure and therefore make the results of this study difficult to interpret.

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