Are EMDR treatment effects solely based upon exposure?

    EMDR (Shapiro)
    • Cognitive-Behavioral Therapy and EMDR Research by Francine Shapiro, 8/4/97

    Are EMDR treatment effects solely based upon exposure?
    by Francine Shapiro, 8/21/97

    Since direct therapeutic exposure treatments have previously been used as a primary cognitive-behavioral treatment of PTSD the question is often raised regarding the extent to which exposure alone is responsible for EMDR effects.

    Since EMDR integrates a large number of procedural elements into its protocols, there is no doubt that exposure is an important element of EMDR treatment. However, according to present theories guiding the use of exposure therapies, it is insufficient by itself to account for the treatment effects, and appears to be used in a contraindicated fashion. Therefore, the form of exposure used in EMDR should be closely examined.

    With EMDR the client is prepared and instructed to remain in contact with the disturbing imaginal experience for a short period of time. The fact that EMDR produces beneficial effects using short doses of exposure should be reconciled with the apparently contradictory observation that a similar periodic interruption of exposure in the context of systematic desensitization fails to attenuate disturbance at the high end of the continuum (Wolpe, 1958). In investigating the form of exposure used in EMDR, it is also important to address the apparently discrepant finding that for flooding a minimum of 25 minutes of continuous exposure is necessary for a significant decrease in distress (Chaplin & Levine, 1981; Foa & Kozak, 1986), and the fact that prolonged (rather than brief) exposure has been proposed as the most effective form of treatment (Chaplin & Levine, 1980; Foa Steketee, & Rothbaum, 1989; Lyons & Scotti, 1995; Marks, 1972).

    Further, the extinction/habituation model upon which exposure therapies are predicated (e.g., recommending 14-50 hours of exposure in combined treatment sessions and homework) does not appear to explain the effects of EMDR (i.e., the remission of symptoms within three sessions). Unlike flooding, EMDR consists of a dosed, sequentially applied exposure, with only a relatively small amount of attention directed at the worst part of the memory, and no exacerbation of the client1s distress by requests of the client to provide more details about a given trauma (see Shapiro & Forrest, 1997, for transcripts of treatment sessions). The achievement of therapeutic effects under these conditions should be investigated to identify the appropriate paradigm necessary with which to explain them. Such a study is particularly important given the observation by behavioral researchers that: 3In strict exposure therapy the use of many of [‘a host of EMDR-essential treatment components1] is considered contrary to theory. Previous information also found that therapists and patients prefer this procedure over the more direct exposure procedure2 (Boudewyns & Hyer, 1996, p. 192).

    Presently, the Accelerated Information Processing model (Shapiro, 1995) is used to explain the observed EMDR effects and has predicted the rapid treatment outcomes which have been obtained. However, the model is purely speculative and open to adjustment based upon empirical findings.

    References

    Boudewyns, P.A. & Hyer, L.A. (1996) Eye movement desensitization and reprocessing (EMDR) as treatment for post-traumatic stress disorder (PTSD). Clinical Psychology and Psychiatry, 3, 185-195.

    Chaplin, E.W., & Levine, B.A. (1981). The effects of total exposure duration and interrupted versus continuous exposure in flooding therapy. Behavior Therapist, 12, 360-368.

    Foa, E.B., & Kozak, M.J., (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99, 20-35.

    Foa, E.B., Steketee, G., & Rothbaum, B.O. (1989). Behavioral/cognitive conceptualizations of post-traumatic stress disorder. Behavior Therapy, 20, 155-176.

    Lyons, J.A. & Scotti, J.R. (1995) Behavioral treatment of a motor vehicle accident survivor: An illustrative case of direct therapeutic exposure. Cognitive and Behavioral Practice, 2, 343-364.

    Marks, I.M. (1972). Flooding (implosion) and allied treatments. In W.S. Agras (Ed.), Behavior modification: principles and clinical applications. Boston: Little, Brown.

    Shapiro, F. (1995) Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures. New York: Guilford Press.

    Shapiro, F. & Forrest, M. (1997). EMDR. New York: Basic Books.

    Wolpe, J. (1958) Psychotherapy by reciprocal inhibition. Stanford, CA Stanford University Press.


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