American Psychological Association, Bennett Braun, Burgus v Braun, DID, Dissociative Identity Disorder, EMDR, Empirically Supported Treatments, Francine Shapiro, Gerald Rosen, Glenna Dunaway, James Herbert, Monica Pignotti, Occam's Razor, Pseudoscience, Richard J. McNally, Scott Lilienfeld, Tony Cotraccia
EMDR: Empirically Supported Treatment or Pseudoscience?
Eye Movement Desensitization and Reprocessing (EMDR) has been classified by the American Psychological Association as having “Strong Research Support” and “Controversial” for treating PTSD (note that this is only for that condition, not for the many other conditions EMDR claims to successfully treat). What does this mean and why the seeming contradiction?
Here are the APA Criteria for Strong Research Support:
I. At least two good between group design experiments demonstrating efficacy in one or more of the following ways:
A. Superior (statistically significantly so) to pill or psychological placebo or to another treatment.
B. Equivalent to an already established treatment in experiments with adequate sample sizes.
II. A large series of single case design experiments (n >9) demonstrating efficacy. These experiments must have:
A. Used good experimental designs and
B. Compared the intervention to another treatment as in IA.
FURTHER CRITERIA FOR BOTH I AND II:
III. Experiments must be conducted with treatment manuals.
IV. Characteristics of the client samples must be clearly specified.
V. Effects must have been demonstrated by at least two different investigators or investigating teams.
Indeed, there are randomized controlled studies that have shown that EMDR does indeed have results that are, as stated in B, “equivalent’ to another established treatment. That treatment is exposure therapy. EMDR itself has elements of exposure therapy, so it is no big surprise that it has been shown to work. The question critics have raised, however, is whether there is anything unique to EMDR that causes it to work and therein lies the controversy.
To date, there is no evidence that anything unique to EMDR is responsible for its beneficial effects. Psychologist Gerald Rosen used the analogy of Purple Hat Therapy. A therapist could don a purple hat, conduct exposure therapy and then claim that it was the purple hat that makes it a very powerful and effective therapy and promote it as a paradigm shift when there is no evidence that the purple hat had anything to do with its success and Occam’s Razor (the simplest explanation that fits the facts is usually the best one) would indicate that it is the exposure driving the success. In essence, the eye movements or other bilateral stimulation of EMDR would be analogous to the purple hat.
Psychologist Richard J. McNally sums it up by stating:
What is effective in EMDR is not new and what is new is not effective.
None of this, however, has stopped proponents of EMDR from making claims that in spite of its APA classification, are not warranted by the research evidence. A case in point is a fairly recent (2009) article in the Ithaca Times where two licensed clinical social workers who are also certified in EMDR, Glenna Dunaway and Tony Cotraccia were interviewed for an article entitled “EMDR Breaks New Ground”. The title and statements made by these therapists imply that there is something unique to EMDR beyond exposure that is responsible for unheard of powerful results, and most confusingly, they claim that there is solid research to support this. What they fail to mention is that none of this research demonstrates that any of the theory they discuss, including bilateral stimulation is responsible for the positive effects. Although there has indeed been much research on eye movements, that research was done by experimental psychologists who study eye movements unrelated to EMDR, hence Cotraccia’s statement appears to me to be quite misleading [this may be unintentional, since it is quite common that masters-level psychotherapists do not have the research expertise to understand these sorts of issues].
The article states:
The new therapies, of which EMDR is now only one, focus on approaching psychological trauma through the body as well as the mind- the traditional talk therapy model. Bilateral stimulation can be eye movement back and forth, or alternating tapping right and left shoulders, or other stimulation such as headphones that play music and switch the sound from one ear to the other.
“We still don’t know for sure how alternating bilateral stimulation works,” says Tony Cotraccia, MSW, another practitioner using the therapy. “The strongest (research) work has been done with eye movement. It definitely improves recall, and reduces the intensity of traumatic memory. It activates parts of the cortex that are involved in mediating emotion.”
“If you’re using the purely cognitive, logical part of your brain in therapy, you’re missing a lot of stuff,” says Dunaway. “The other thing that has become evident in the research over the last few decades is the mysterious connection between the body and the mind.” Dunaway cites a man who was in psychotherapy for years, with slow results, who found he became much better after he took up tennis. “Alternating bilateral stimulus of any kind will do something to help us process old stuff,” she says. The difference between taking a walk in the park and using EMDR therapy is that the therapist keeps you focused, “so you’re not daydreaming.”
“When there’s a hurricane or a tsunami, there are little troops of EMDR people flying in and they actually have people sit down in circles and pat their shoulders,” says Dunaway.
However, other than the research showing EMDR comparable to exposure therapy (and even that is mixed, with some studies showing the superiority of plain old exposure therapy) there is no research to support these fantastic claims and there is no indication that the so-called “mind-body connection” has anything to do with any positive results obtained with EMDR. Also note that claims are being made for an entire class of “new therapies of which EMDR is only one”. What are these therapies? One can only guess, but the passage implies that they are referring to mind-body therapies, most of which have little, if any research to support their efficacy.
Some people wonder what difference it makes how a treatment works, as long as it does work? It makes quite a bit of difference. For people who believe it is the bilateral stimulation, that will lead to the rather bizarre further developments, such as the treatment described in the article of having people sit in a circle and tap one another’s shoulders, rather than the element of the therapy that has been shown to work, plain old exposure therapy, which is actually denigrated by some EMDR proponents. For example, EMDR proponent Robin Shapiro (no relation to Francine) claims that EMDR and some of the other therapies she writes about in her Trauma Treatment Handbook (2010, Norton) are superior to exposure therapy. Although exposure therapy for trauma has by far the most evidence to support its efficacy, Robin Shapiro denigrates it and offers up her own clinical anecdotes of how she has been sent clients who failed at well respected clinics who she was later able to help with EMDR and other new treatments. However, she offers no objective evidence that this is so and thus, there is no way to evaluate her claims, which are based on on carefully conducted research, but rather, on anecdotes. That book uncritically presents a number of controversial therapies that are lacking in good research support such as Energy Psychology (TFT, EFT and other tapping therapies), Somatic Therapies, as well as some highly controversial treatments for Dissociative Identity Disorder (DID) and parts work that as far as I have been able to determine have no solid evidence to support their efficacy or even that they do no harm. Her citing of Bennett Braun as if he were a well respected expert, in light of the infamous Burgus v Braun which resulted in a $10.6 million settlement in favor of the plaintiff who was his former patient, especially concerns me. There have been enough reports of harm from DID therapy, that Scott Lilienfeld in his publication on therapies that cause harm, classified it as potentially harmful. To me, it is very concerning that therapists even today, are practicing all kinds of practices which have not been subjected to rigorous testing, that for all we know, may be making clients worse rather than better.
To get back to the topic at hand, EMDR, we can observe how promotion of EMDR and its theories of bilateral stimulation, which have yet to have empirical support, can be used as a springboard for the promotion of all kinds of therapies that have no support whatsoever.
An article I highly recommend for further discussion is a publication by James D. Herbert and his colleagues, full text available online, Science and Pseudoscience in the Development of Eye Movement Desensitization and Reprocessing. The authors discuss how, in spite of its empirical support, EMDR has a number of characteristics of a pseudoscience. This article gives an excellent overview of how pseudoscientific practices are marketed that apply to a number of different practices besides EMDR and also gives an excellent overview of the research up to that time (2000). Since that time, there are still no well-designed, controlled studies that I am aware of that show that the eye movements or bilateral stimulation have anything to do with why EMDR works as a trauma treatment.
The lesson in all this is that when it comes to “trauma experts’, caveat emptor. Ask for evidence, rather than anecdotes for these so-called powerful new therapies so widely promoted in the media.