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  EMDR & Other Neoteric Approaches to PTSD Treatment

(© Anne Dietrich, Louise Maxfield, Anna Baranowsky, Mona Devich Navarro, J. Eric Gentry, Chrys J. Harris, Charles Figley, 1999)

This paper focuses on a critical review of contemporary approaches in the treatment of Post Traumatic Disorders. Five treatments are reviewed in terms of treatment efficacy and suitability for treatment of various forms of traumata. The treatments we have covered, in alphabetical order, include Eye Movement and Desensitization Reprocessing (EMDR; Shapiro, 1989a, 1989b, 1995), Thought Field Therapy (TFT; Callahan & Callahan, 1996, 1997), Time-Limited Trauma Therapy (T-LTT; Tinnin 1994a, 1994b, 1994c, 1995a, 1995b, 1996, 1997); Traumatic Incident Reduction (TIR; French & Harris, 1998; Gerbode, 1995), and Visual/Kinesthetic Dissociation (V/KD; Bandler & Grinder, 1979). For each approach, we describe the theoretical underpinnings and practical applications, provide a review of clinical and/or empirical literature, and offer recommendations regarding future practice with each of these treatments.

Method for Gathering Information

Literature searches were conducted through PILOTs, PsychInfo, PsychLit, and Medline databases, personal communications with PTSD clinicians and researchers, reference lists of articles and books, and perusal of resources on the Internet.

Description of Techniques

Each of the five techniques is described below, in alphabetical order. Studies are examined in terms of Levels of Evidence adopted from the Agency of Health Care Policy and Research (AHCPR).


Eye Movement and Desensitization Reprocessing

Eye Movement Desensitization and Reprocessing (EMDR) is described by originator Francine Shapiro as "a model, set of principles, procedures and protocols that together represent a new approach to psychotherapy" (1994a, p.155). This therapeutic process integrates elements of many different therapies into a structured protocol. EMDR is hypothesized to facilitate the accessing and processing of traumatic memories and to bring these to an adaptive resolution by desensitizing emotional distress, restructuring associated negative cognitions, and relieving accompanying physiological arousal. Shapiro's (1995) Accelerated Information Processing model provides a hypothesis of how the combined procedural elements and directed dual stimulation activate and accelerate the brain's own information processing system, with its inherent self-healing processes. Experiences are understood as being stored in memory networks, which are organized by affect, and which contain related memories, thoughts, images, emotions, and sensations. Shapiro suggests that a traumatic experience may cause an imbalance in the physiological system, with the result that the experience is not processed and the information is maintained neurologically in a distressing, excitatory, state-specific form.

According to Shapiro’s theory, EMDR facilitates adaptive reprocessing that takes place on a neurophysiological level, with a shift in memory storage as the targeted memory network links up with more adaptive information, producing insight and integration. The adaptive resolution includes appropriate affect, self-attribution, and overall assessment. The theory further suggests that, because the information is linked associatively, treatment effects will generalize to each event clustered in that memory network and to other similar memories. All this is said to occur at a rapid pace. Thus far, there is no conclusive empirical evidence to support this theory.

According to Hyer and Brandsma (1997), EMDR is a complex multi-component, multi-staged process, combining many elements of other effective therapies into a comprehensive treatment protocol. It consists of eight phases, each considered essential for effective application (Shapiro, 1995; Shapiro & Forrest, 1997). Critics charge that the focus of the first three phases is common to most treatments of PTSD, and that the focus of all eight phases is similar to that of cognitive behavioral therapy (CBT) techniques. Although most treatments include elements of history taking, assessment, and exposure, the EMDR protocol applies these elements in a unique fashion, one that is both highly structured and client directed. EMDR is also unique in its holistic approach, with its attention to ongoing physiological changes throughout the session.

During the first two phases the therapist develops a treatment plan, assesses the client’s suitability for EMDR, and prepares the clients by educating them about the process and teaching them self-control techniques and affect management skills. In the third phase the clients identify a specific target memory, with its related image, affect, cognitions, and body sensations. The clients are assisted in both identifying a “negative cognition,” which is a current negative self-referencing belief elicited by the target memory, and in developing a related “positive cognition,” which expresses a desired sense of empowerment and agency. The clients rate the validity of the positive cognition on the Validity of Cognition Scale (VOC). Then, pairing the image with the negative cognition, the clients identify the related emotions and body sensations and give a Subjective Unit of Distress (SUD) rating for the level of distress.

In the fourth phase, the desensitization phase, the clients focuses on this material while experiencing bilateral stimulation in sequential dosed exposures. The clients holds all these elements in mind (the image, negative cognition, affect, and body sensation), while simultaneously moving their eyes from side to side for approximately 30 s, following the therapist’s fingers as they move across the visual field. After the set of eye movements the clients are told to take a deep breath, and then are asked what new material was elicited in the process. The new material (image, thought, sensation, or emotion) then becomes the target of the next set of eye movements. This cycle of alternating focused exposure and client feedback is repeated many times and is accompanied by shifts in affect, physiological states, and cognitive insights. If the processing stalls, the therapist uses “cognitive interweaves,” which are specialized interventions to facilitate information processing. This phase continues until periodic checks of the SUD level and of the original target indicate that the memory has been desensitized. A SUD rating of 0 or 1 indicates completion of this phase. Other bilateral stimuli such as hand-tapping or aural stimulation can replace the eye movements (Shapiro, 1991; 1994b; 1995).

In the fifth phase, cognitive installation, the therapist invites the client to pair the previously identified positive self-referencing belief with the original traumatic event, using bilateral stimulation. The efficacy of this phase is measured by the client's self-reported VOC. An attempt is made to bring the VOC to a score of 6 or 7. EMDR theorists believe that there is a "physical resonance to unresolved thoughts” (Shapiro & Silk Forrest, 1997, pp. 54-55) and that processing is not complete until the client can bring the traumatic memory into consciousness without feeling any body tension. This is assessed in phase 6, preparatory to closure in phase 7. The therapist assesses that the material has been adequately worked through, and if not, assists the client with self-calming interventions. Reevaluation (phase 8) takes place at the beginning of every EMDR session. The therapist checks with the client via SUD, VOC and body self-report measures, to assure that the treatment gains have been maintained. These reevaluations assist the therapist in continuing to direct the treatment to achieve maximum benefit for the client.

EMDR is both highly structured and client directed. It possesses a number of effective nonspecific therapeutic components, including therapeutic rapport, client empowerment, and expectations of positive outcome. It also incorporates many features of CBT, with components of cognitive restructuring, anxiety desensitization, breathing, and exposure. Cognitive behavioral theorists such as Lohr, Tolin, and Lilienfeld, (1998) insist that EMDR should be considered a variant of CBT. However, EMDR also incorporates elements of many other effective therapies such as psychodynamic, body-oriented, person-centered, and interactional therapies. Shapiro maintains that EMDR, with its structured dosed exposure, dual stimulation, and therapeutic protocol, is a distinctly different form of therapy, activating internal processes that move the individual toward healing.

Summary of the Literature

Since Shapiro's first published articles on EMD in 1989, there have been ongoing debates and dialogues concerning its efficacy and Shapiro's theory. The purpose of this paper is not to arrive at a definitive conclusion about EMDR; instead, the research is objectively described, limitations and strengths are identified, controversial issues are explored, and the perspectives of both critics and advocates are explained. This paper attempts to be unbiased in its examination of the data.

A number of empirical studies have demonstrated EMDRs effectiveness as a treatment for PTSD. In a meta analysis that examined comparative efficacy of treatments for posttraumatic stress disorder, Van Etten and Taylor (1998) analyzed 61 treatment outcome trials from 39 studies of chronic PTSD, using pharmacotherapies, psychological therapies (behavior therapy, EMDR, relaxation training, hypnotherapy, and dynamic therapy), and control conditions (pill-placebo, wait-list controls, supportive psychotherapies, and non-saccade EMDR control). Among the psychological therapies, behavior therapy and EMDR were most effective, and generally equally so. The effect sizes (using Cohen's d statistic) of all the various control conditions were about 0.3 and the effect-sizes of the exposure and EMDR therapies were about 1.8. The authors state that EMDR is an effective treatment for PTSD, and that EMDR treatment had significantly fewer sessions than behavior therapy (4.6 vs. 14.8) and took significantly less time (3.7 vs. 10.1 weeks). However, meta-analysis should not be used to determine the relative efficiency of treatments; thus it cannot be conclusively determined that EMDR is a more rapid treatment than CBT because direct comparisons require the same population being randomly assigned to treatment conditions within the same research design.

The following seven randomized, controlled, clinical studies with traumatized subjects were chosen for review because they meet the majority of Foa and Meadow’s Gold Standards (Foa & Meadows, 1997). Component studies that use alternate bilateral stimulation for control groups (e.g. Pitman et al., 1996) are discussed in the section on the efficacy of eye movements. They are not used to evaluate treatment efficacy because they control only for one aspect (eye movements) of a complex process, and may not exclude the effective mechanism, which could be focused attention, stimulation of an orienting response, bilateral activation, or rhythmic activity (Shapiro, 1995). Most of these elements are integral to control conditions such as finger tapping or visual focus on a dot; these conditions are considered by Shapiro (1991) to be variants of EMDR and to create the same effect as eye movements. This controversial issue is discussed in more depth in the section on eye movement efficacy.

EMDR Compared to Wait List Controls.

Wilson, Becker, and Tinker (1995; 1997) randomly assigned a mixed sample of 80 traumatized individuals to EMDR treatment or delayed-EMDR treatment conditions and to one of five trained clinicians. A structured interview (the PTSD-1) was used at pre-session assessment before subjects were assigned to conditions and 46% of the subjects were objectively diagnosed with PTSD. The PTSD-1 was not used at post-treatment, so change in PTSD diagnosis cannot be determined. Wilson et al. performed a linear regression analysis that indicated that treatment gains did not vary as a function of symptom severity or PTSD diagnosis at pre-treatment.

Each subject received three 90 minute sessions of EMDR. A blind independent assessor administered all self-report measures at pre and post treatment and at three month follow-up. The measures consisted of the SUDS and three standardized tests with their various subscales: the Symptom Checklist, Revised (SCL-R-90), the State Trait Anxiety Inventory (STAI), and the Impact of Event Scale (IES). Significant differences were found between groups on all measures, and the EMDR group showed significant improvement at post-treatment and 3 month follow-up. This improvement was also clinically significant: At pretreatment the means on all measures were at or above a normative Z score of 1.0. At post-treatment, the means decreased to a within normal limits range. Treatment gains were strongest for those measures specifically related to the trauma. The replication of treatment effects for the wait list group showed significant effects for all measures, and was clinically equivalent to the immediate treatment group. A limitation of this study is the possible lack of generalizability to patients with PTSD because not all subjects had PTSD.

Thirty-two of the original 37 subjects with PTSD participated in an assessment at 15 month follow-up. On the PTSD-1, there was an 84% reduction in PTSD diagnosis compared to pre-treatment: Only 5 subjects still met PTSD criteria. All subjects reported significantly fewer PTSD symptoms compared to pretreatment. Because there was no control group (the delayed treatment group now being part of the treatment group), comparisons were made between pre-treatment, post-treatment and follow-up scores. This design does not control for influences during the 15 month period so it is not possible to conclude that the maintenance of post-treatment outcome resulted solely from EMDR treatment effects.

Rothbaum (1997) randomly assigned 21 adult women who had been raped and who all met criteria for PTSD to three sessions of EMDR or to a wait-list control group. Results were evaluated by a blind independent assessor using structured interviews and self-report measures. The scores of the EMDR participants on the PTSD Symptom Scale (a structured interview), Beck Depression Inventory (BDI), and IES showed a mean decrease of more than 2Z scores at post-treatment, which was significantly different from the wait-list control. EMDR subjects also showed a large decrease on the Rape Aftermath Symptom Test of 1.8 Z scores, but this was not significantly different from the wait-list group. Although decreases on other self-report measures were not significant, mean scores of the EMDR group decreased to within normal limits range. Only one patient (10%) in the EMDR group met full criteria for PTSD at post-treatment, compared to 88% of the wait-list group. A limitation of this study is the lack of a treatment control group to control for non-specific treatment effects.

These studies by Wilson et al. (1995; 1997) and Rothbaum (1997), in which EMDR was compared to wait list controls, indicate that EMDR is superior to no treatment in reducing subjective distress. The design of such studies is limited: There is no control for nonspecific factors such as therapeutic alliance, expectations, or placebo effects, and no comparison is made to other treatments. Nevertheless, these studies show strong therapeutic effects, with 84% to 90% of subjects no longer meeting PTSD criteria after three sessions of EMDR.

EMDR Compared to Other Treatments

Marcus et al. (1997) compared EMDR to “Standard Clinical Care” (SC) in an HMO. SC consisted of individual therapy with possible additions of group therapy and medication. Sixty-seven individuals diagnosed with PTSD according to DSM-III-R criteria were randomly assigned to EMDR treatment or SC treatment. There was no limit to the number of sessions received. Data was collected by an independent evaluator who assessed participants using interviews and multiple standardized self-report measures at pretreatment, after three sessions, and at the completion of treatment. The measures included the Modified PTSD Scale (MPTSD), the BDI, the STAI, the IES, and the SCL-90. The individuals in the EMDR group attained symptom reduction with significantly greater rapidity and had significantly fewer treatment sessions than the SC group. EMDR produced significantly lower scores than SC after 3 sessions and at treatment completion for PTSD symptoms (MPTSD, IES), depression (BDI), and anxiety (STAI-trait, SCL-90, and SUDS). The researchers note that after three sessions, only 50% of the EMDR participants still met the criteria for PTSD, compared to 70% of the SC group. At post-treatment, only 23% of the EMDR group met criteria for PTSD compared to 50% of the SC group.

Limitations of this study include the 50 minute limit on sessions and the unlimited number of sessions. Although the wide variety of treatments used in the control group (cognitive, psychodynamic, behavioral, medication, group, relaxation) accurately represents standard care in an HMO setting, their amorphous nature precludes any specific conclusions about treatment of the control group. There is no identification of, or control for, important therapist variables. Moreover, it is not possible to ascertain how subject expectations were influenced by condition assignment.

Carlson et al. (1998) tested the effect of EMDR on 35 Vietnam combat veterans suffering from PTSD. Subjects were randomly assigned to a biofeedback relaxation treatment group, to a wait list control, or to an EMDR group. The subjects in both treatment groups received 12 treatment sessions from trained and experienced clinicians. Standardized self-report measures were administered at pretreatment, post-treatment and 3 month follow-up by the authors, and at 9 month follow-up, by a trained blind assessor. Measures included the Mississippi Scale for Combat Related PTSD, the IES, the PTSD Symptoms Scale (PSS), the BDI, and the STAI. A structured interview, the Clinician Administered PTSD Scale (CAPS) was administered at pretreatment and 9 month follow-up. Physiological measures were also taken in which previously taped traumatic scenarios of 30-45 sec duration were played. Baseline physiological measures were taken during pretreatment assessment and at each of the assessment periods.

At 9 month follow-up with a blind independent assessor, EMDR treatment was found significantly superior to relaxation therapy on the CAPS, BDI, Mississippi, and the Global Clinical Rating. On the physiological measures, there was no difference between groups and both treatment groups showed significant main effects for treatment. The decrease in physiological arousal was maintained at follow-up. The authors note that they had no treatment bias favoring EMDR since they had worked with other treatment models, and in particular with relaxation therapy, in the PTSD field for many years. Because relaxation therapy has not been designated an efficacious treatment for PTSD, it could be argued that this study does not compare EMDR to another acknowledged effective treatment, but only controls for some of the nonspecific effects of treatment. However, relaxation therapy has been widely used for combat veterans with PTSD and has been found effective in randomized controlled studies (Peniston, 1986; Peniston & Kulkosky; 1991).

Boudewyns and Hyer (1996) sought to evaluate the addition of EMDR to standard group therapy in the treatment of 61 combat veterans with chronic PTSD who were considered multiply disabled and most of whom were receiving disability pensions. Subjects were randomly assigned to one of three conditions: EMDR, EC which was an EMDR variant with eyes closed, or standard group therapy. All conditions received 8 sessions of group therapy, and the EMDR and EC conditions received 8 treatment sessions of EMDR or EC in addition to group therapy. Measures were collected by a blind independent assessor, and included the Structured Clinical Interview (SCID), the CAPS-1, IES, and Profile of Mood Scale (POMS). The researchers also collected physiological measures, including heart rate. They found that all three conditions improved significantly on the CAPS, with no group differences. Subjects in the EMDR and EC conditions improved significantly more on the POMS and physiological measures compared to group therapy controls. The control group experienced an increase in heart rate when exposed to trauma scripts, while the EMDR and EC groups experienced a decrease in physiological arousal with exposure to trauma scripts. A limitations to this study is that the time per session was undocumented. Because the EMDR and EC groups were also receiving group therapy, it is not possible to determine the unique effects. Boudewyns and Hyer report that both therapists and clients preferred EMDR to the more direct exposure condition.

Scheck, Schaeffer, and Gillette (1998) compared EMDR to an Active Listening control with a group of 60 traumatized young women. Inclusion criteria were a traumatic memory and a recent history of “dysfunctional behavior” such as sexual promiscuity, runaway behavior, or drug and alcohol abuse. Seventy-seven percent of the subjects were diagnosed with PTSD, through a structured interview, the PTSD-1. The women received two treatment sessions of 90 minutes each. Multiple outcome measures of depression (BDI), anxiety (STAI- state) self-concept (Tennessee Self-Concept Scale) and post-traumatic stress (the Penn Inventory for PTSD and the IES) were taken at pre and post treatment. Post treatment measures were collected by a blind assessor. Scheck et al. found that although both treatments resulted in a significant reduction in pre and post self-reported symptoms, the effects of EMDR were significantly greater on all measures. This was most evident for the IES, the measure that was most trauma specific.

When Scheck et al. (1998) compared treatment outcome for the patients with PTSD diagnoses at pre-treatment and those without PTSD, they found that there were no significant differences on any of the outcome measure change score means. They concluded treatment gains were equivalent for those with and without PTSD diagnoses at pretreatment. This suggests that the findings can be generalized to PTSD patients. However, no assessment was made post-treatment of the PTSD status of the subjects so it is not known if the treatment resulted in a change in PTSD diagnosis. This study indicates that EMDR is superior to a condition that controls for some of the nonspecific effects of treatment such as attention, therapeutic rapport, and active listening.

The Carlson et al. (1998), Marcus et al. (1997), and Scheck et al. (1998) studies suggest that EMDR is more effective in the treatment of PTSD than SC, relaxation therapy, and active listening. Relaxation therapy and EMDR had equivalent effects in decreasing physiological arousal. Limitations to these studies include the lack of established efficacy for either SC or active listening in the treatment of PTSD. The Boudewyns and Hyer study (1996) suggests that the addition of EMDR or an EMDR variant to group therapy may improve treatment outcome.

EMDR Compared to Exposure Therapy

In one of the first studies to compare Cognitive Behavior Therapy (CBT) and EMDR, Devilly & Spence (in press) determined that a CBT variant developed by Devilly, entitled Trauma Treatment Protocol (TTP), was superior to EMDR. TTP combines elements of CBT and Stress Inoculation Training and Prolonged Exposure. Twenty-three civilian subjects with PTSD were randomly assigned to seven sessions of either EMDR or TTP. Although subjects were assessed by the therapist/researchers on the PTSD-1 scale, at post-treatment the Wilson et al. (1995) revised scale was used, although no acknowledgment is made of its lack of established validity. Ten self-report measures were used; several of these were non-standardized, non-validated measures. Standardized measures included the STAI, BDI, SCL-90-R, SUDS, Civilian Mississippi Scale, IES, PTSD Symptom Scale Self-Report (PSS-SR), and the PTSD-1. The non-standardized measures, two of which were written by Devilly and colleagues, were the Personal Problem Definition Questionnaire, the Treatment Evaluation Form, and the Distress Evaluation Scale for Treatment. Limitations of this study include the large number (at least 34) of statistical analyses done with no Bonferroni correction for Type I error, and the MANOVA performed on the PTSD measures with no concern for multicollinearity and without excluding the nonvalidated Revised PTSD-1. No individual analyses were reported for PTSD measures. Although Devilly & Spence (in press) state that treatment integrity was rated by a local EMDR therapist who gave them exceptionally high ratings, their description of the technique shows a lack of conformity to standardized procedures (Devilly, Spence, & Rapee, 1998).

Although these statistical and methodological problems confuse the findings of Devilly and Spence (in press), it is apparent that they found TTP significantly more effective than EMDR on combined PTSD measures, and on the SCL-Global scale. Both EMDR and TTP were found to be significantly effective on all measures. At three month follow-up, scores on the self-report PSS-SR indicated that 58% of the TTP subjects no longer met PTSD criteria compared to only 18% of the EMDR group. The lack of a structured interview to determine PTSD diagnosis is a limitation of this study as is the 37% drop out rate in the EMDR group. The researchers suggest that the apparent superiority of TTP may be due to skill learning and the consolidation of anxiety management techniques.

This assumption of efficacious equivalency was the starting point of a study that sought to examine differences in process between EMDR and exposure therapy. Rogers et al. (in press) used a single session of treatment which focused on the most distressing identified combat memory. Twelve combat veterans with PTSD were randomly assigned to EMDR or Exposure. Rogers at al. found that both groups significantly improved on the IES (as it was applied to that particular memory), and they noted a trend toward a decrease in heart rate reactivity for both groups. A behavioral measure in which subjects monitored the severity of intrusive recollections showed a significant decrease for the EMDR group compared to the Exposure group. Comparing in-session process, the researchers noted that SUD ratings were taken more often during the Exposure condition, and that EMDR resulted in a significantly greater decrease in SUDS. A limitation of this study is that the amount of time spent in script development may have decreased the amount of time available for therapy for both groups. Only one session of treatment was provided and the purpose of the study was a comparison of therapeutic process, not of treatment efficacy; the results must be considered in this context.

The comparison of EMDR to exposure therapies and to CBT is an area where further research is essential. Devilly and Spence (in press) found that therapy that combined exposure and skill training was superior to EMDR on self-report measures. Rogers et al. (in press) also found relatively equivalent results, with a slight superiority for EMDR, but were not assessing treatment efficacy.

The Efficacy of Eye Movements

Originally Shapiro (1989a; 1989b) believed that the rhythmic multi-saccadic eye movements were an essential feature of the EMD process. Later this was revised to include other rhythmic bilateral movement or stimulation such as finger tapping and audio stimulation, and then further extended to include any external focus, including eyes focused and unmoving (Shapiro, 1991). Although modifying theories to incorporate new empirical data is well within the standards of established science, critics argue that Shapiro continues to change the operational definition of EMDR. DeBell and Jones (1997) question if future researchers will be able to develop alternate controls that “Shapiro and her followers will not criticize as a type of bonafide EMDR” (p.161). Lohr et al. (1998) argue that if the characteristic features of EMDR cannot be determined and tested, then they cannot be experimentally disconfirmed, and the process of scientific inquiry becomes irrelevant.

The use of EMDR variants as control conditions in treatment efficacy studies remains highly controversial. Lohr et al. (1998) insist that designs that compare the eye movement protocol to finger tapping or auditory stimulation are adequate to test whether EMDRs effects can be attributed to nonspecific effects. But advocates identify these alternate methods as EMDR variants, and insist that such variants also contain the effective mechanism and yield effects equivalent to those of eye movements. Shapiro (1991; 1995) has long maintained that the effective mechanism in EMDR is not the movement of the eye but the cognitive processes associated with dual attention, i.e., the simultaneous internal and external focus. Because of this, the use of alternate bilateral stimulation as controls in efficacy studies is inappropriate. In addition, the EMDR process involves structured short doses of alternating exposure; this structured process is replicated in all the variants, and it may have a specific treatment effect. Feske (1998) argues that component studies and efficacy studies must be differentiated.

Most published reports of attempted component analysis suffer from poor methodology, and some studies were done with subjects without PTSD. There is some support for the importance of eye movements (Montgomery & Allyon, 1994; Renfrey & Spates, 1994; D. Wilson, Silver, Covi, and Foster, 1996 ) and some evidence that eye movements may not be necessary (Boudewyns & Hyer., 1996; Devilly et al., 1998; Pitman et al., 1996). Montgomery and Allyon used a multiple-baseline design with a sample of 6 subjects. They found significant decreases for the eye movement condition on SUDS, BDI, and self-reports of intrusive images and dreams, but the decrease in physiological measures was not significant. The small sample size and lack of a control condition limits these findings.

D. Wilson et al. (1996) randomly assigned a mixed trauma population, 61% of whom were diagnosed with PTSD, to 3 conditions: EMDR with eye movements, hand taps, or no eye movement. They each received one session. Significant differences were found using physiological measures (including galvanic skin response, skin temperature, systolic blood pressure, and heart rate) and the SUD Scale. The results revealed, for the eye movement condition only, a one-session desensitization of subject distress and an automatically elicited and seemingly compelled relaxation response, which arose during the eye movement sets. Treatment gains either maintained or increased at the 1 year follow-up. The generalizability of these findings to PTSD populations is limited given the mixed nature of the sample.

Renfrey and Spates (1994) randomly assigned 23 PTSD subjects to 3 variants of EMDR treatment: eye movements tracking a clinician's finger, eye movements tracking a light bar, and EMDR using fixed visual attention. All three conditions produced positive changes on the CAPS, SCL-90-R, IES, SUDS, and heart rate. Although there were no significant differences between groups, the number of subjects with PTSD decreased most in the two eye movement groups: At follow-up, 1 subject in each of the eye movement groups met PTSD criteria compared to 3 subjects in the eye fixation group.

Using a sample of 61 combat veterans with PTSD, Boudewyns and Hyer (1996) had an eyes-closed-EMDR condition (EC), which produced results not significantly different from standard EMDR. This control group did not use any external focus and so it appears that none may be necessary. The findings of this study call into question the hypothesized mechanism of dual focus. Pitman et al. (1996) compared EMDR to a fixed eye with finger tapping control, and found no differences between groups. They used a cross-over design with 17 combat veterans with PTSD. Devilly et al. (1998) compared 2 sessions of EMDR to 2 sessions of an EMDR variant with fixed eyes and found no significant differences between the two groups, although both groups improved on a trauma measure compared to a standard care control group. There was a nonsignificant trend for better outcome for the EMDR group, 67% of whom showed reliable improvement compared to 42% of the fixed eye group. The 51 combat veterans in this study were also receiving a variety of other unspecified concurrent treatments.

All these studies suffer from methodological short-comings and the findings are inconclusive. Studies with civilian subjects have found stronger treatment effects for EMDR with eye movements compared to EMDR variants. Studies with combat veterans suggest that EMDR with eye movements is comparable to EMDR with an alternative focus or that no lateralizing focus may be necessary. Pitman et al. (1996) conclude that since eye movements may be deleted without loss of treatment gain, this falsifies neurological explanations of the role of eye movements, and this has led many (e.g., Lohr et al., 1998) to conclude that EMDR without eye movements is equivalent to CBT or exposure therapy. However, Shapiro (1995) argues that the physiological mechanisms are activated by alternate types of external focus. It is apparent that further research with better methodology is needed to clarify this contentious area.

Critique

It is apparent that EMDR is an effective therapy for PTSD. It is also apparent that the mechanism of action is unknown. The research has failed to address and test Shapiro’s theory of accelerated informational processing or to evaluate the numerous hypotheses about treatment mechanisms such as distraction, disinhibition, extinction, cognitive restructuring, and dosed exposure. Research is needed to determine the mechanism of action, and the contribution of the procedural elements to the treatment effects. Component studies should examine the role of the various elements such as exposure, external focus (eye movements and bilateral stimulation), affective arousal, physiological arousal, and cognitive processing.

Lohr et al. (1998) maintain that EMDR is just a variant of cognitive behavioral exposure therapies. However, the non-directive free association method used in EMDR is very different from exposure therapies which employ a chronological concentrated focus on the traumatic event. Unlike traditional exposure therapy which uses prolonged exposure (Foa & McNally, 1996), EMDR uses alternating, multiple, brief exposures to high levels of disturbance, and patients may spend very little time exposed to the details of the trauma. The role of the dosed alternating exposure in EMDR has yet to be determined.

Some critics (e.g., Rosen, Lohr, McNally, & Herbert, 1998) insist that EMDRs only novel feature is the eye movement, and contend that the eye movement component is unnecessary and spurious. Although there is some research that indicates that EMDR with eye movements is comparable to EMDR with an alternative external focus, there are other studies indicating that eye movements contribute to EMDRs effectiveness. As Lohr et al. (1998) point out, adequate controls must be developed to evaluate the role of EMDR treatment components. At present the research is inconclusive and this area remains contentious.

Although it can be concluded that EMDR is an effective treatment for PTSD it is not clear how it compares to CBT and exposure therapies. One study showed some superiority for exposure therapy combined with skills training; other studies have shown relative equivalency. Research is required to examine EMDRs efficacy by directly comparing it with cognitive behavioral techniques such as exposure therapy and stress inoculation training to assess relative effectiveness and efficiency. Such studies must use an adequate number of sessions and long term follow-up to assess each treatment’s utility with chronic PTSD populations.

Although Boudewyns and Hyer (1996) indicated that EMDR was better tolerated by patients than exposure therapy, this was not the finding of Devilly and Spence (in press) or of Rogers et al. (in press) whose subjects rated the procedures equally. Rogers et al. speculate that this impression of better tolerance may be related to the rapid drop in SUDs with EMDR.

Shapiro (1993; 1996a; 1996b) has consistently maintained that poor treatment fidelity results in poor treatment outcome. Lohr et al. (1995) disagree with how Shapiro evaluated treatment fidelity in studies which found no effect for EMDR and argue that these studies did have adequate treatment fidelity. Nonetheless, Lohr et al. agree that treatment fidelity is critically important when the procedure being tested is “structured and prescriptive, as is EMDR” (p.287): Assessment of empirical validity requires the faithful application of the protocol. The issue appears to be the determination of treatment fidelity. It is apparent from their description of EMDR technique (Devilly et al., 1998) that Devilly and Spence (in press) had poor treatment fidelity, yet their performance of the method was evaluated as “acceptable” by an untrained assessor. This is the only one of the efficacy studies reviewed in this paper that had poor treatment fidelity and this is also the study which had poor treatment results. Only 18% of their EMDR subjects no longer met the criteria for PTSD diagnosis compared to 77% of the subjects from Marcus et al (1997). Pitman et al. (1996) report significant correlations between ratings of treatment fidelity and client outcome as measured on the CAPS.

Lohr et al. (1998) suggest that there is a problem of investigator bias which should be reconceptualized as treatment allegiance effects; they imply that positive treatment effects can be attributed to such a procedural artifact. However, EMDR allegiance effects are seemingly non-existent in studies by Boudewyns and Hyers (1996) and Carlson et al. (1998), both of whom had allegiances to other methods (exposure and biofeedback respectively) and who reported that EMDR was the preferred method.

 

Thought Field Therapy

Thought Field Therapy (TFT; Callahan, 1996) interventions are targeted on two areas: negative emotions and deeply held beliefs regarding trauma; and energy imbalances in the body's "bioenergy control system" (p. 131). According to Callahan, the basic cause of negative emotions is “perturbations in the thought field" (p. 130) -- cognitions that function to trigger negative emotions associated with trauma. Callahan views these perturbations as imbalances that are encoded in the body's bioenergy system. He asserts that simultaneous activation of the body’s physical bioenergy systems, as well as emotions and/or beliefs related to the trauma, are necessary if the intervention is to be effective. This activation of the physical system is accomplished through the tapping of several pressure points arranged in a predetermined sequence, the configuration of which is based on the meridian system of acupuncture. Several algorithms have been identified by Callahan, and they vary depending on the presenting symptoms. Callahan and Callahan (1997) have postulated that the affective changes observed when utilizing TFT are mediated by fluctuations in neurotransmitter and ion concentrations during the procedure.

During the procedure, clients are taught to “tune” the “thought field” (p. 130), where they think about the targeted emotion and report a Subjective Units of Distress (SUD) rating from 1-10 (10 being the most distress). According to Callahan, the client’s reported SUD rating should progressively decrease in intensity as the various pressure points are briefly tapped on.

Summary of Literature

No controlled, randomized treatment outcome research has been conducted.

Critique

A major limitation of TFT is the lack of controlled, randomized studies. Another limitation is that the subjective reporting of SUD levels is the main basis upon which Callahan measures his treatment’s effectiveness. It is conceivable that the client’s reported reduction in SUD levels after the tapping is a function of factors other than opened energy systems. Callahan’s hypothesis that maladaptive thoughts and emotion are encoded at peripheral meridian points does not appear to be consistent with well-established physiological and anatomical data (e.g., see Gazzaniga, 1995) that cognitions are processed by way of the Central Nervous System. To support their hypothesis that TFT outcome is mediated by ionic and neurotransmitter changes, Callahan and Callahan (1997) cite evidence from a series of experiments that show that electromagnetic stimulation can induce gradient changes in the extraneuronal area on isolated chick cerebral cortex and intact feline cerebral cortex. However, it is not evident that electromagnetic stimulation of cerebral cortex relates in any way to mechanical sensory stimulation of the peripheral nervous system. It appears more plausible that the repeated exposure to the disturbing cognition, along with the distractive behavior of tapping, may produce a reciprocal inhibitory reaction that de-conditions the stressor.

 

Time-Limited Trauma Therapy (T-LTT)

Time-Limited Trauma Therapy (T-LTT; Tinnin, 1994a, 1994b, 1994c, 1995, 1996, 1997) is a theory-driven protocol developed by Louis Tinnin, M.D. in 1991. A treatment manual was published in 1994 and since that time hundreds of patients with posttraumatic stress and dissociative disorders have been successfully treated (Tinnin, 1995b, 1996). The procedure uses a combination of relaxation induction, visualization, voluntary dissociation, narration, art therapy, focal psychotherapy, video-technology, and integration to process traumatic memories with minimal abreaction and painful re-experiencing. This treatment approach incorporates the dissociative model formulated by Pierre Janet in France one hundred years ago (van der Hart & Horst, 1989), with the aim to facilitate access to dissociated traumatic memories and bring them to closure.

The three phases of treatment in the dissociative model are: (1) management of trauma phobia; (2) "trauma work," or, memory processing; and, (3) management of complications. These phases are analogous to Herman's (1992) "Safety, Remembrance and Mourning, and Reconnection," with the exception that the first phase of the dissociative model is much shorter in duration if the patient is not regressed.

Trauma work is the major thrust of treatment. Its’ goals are to eliminate intrusive symptoms within weeks; diminish avoidant and dissociative symptoms within a few months; and, finally, reverse alexithymia within six months after the termination of treatment. The objectives of trauma work are to process traumatic memories chronologically by verbal and nonverbal methods and to avoid abreaction or emotional re-experiencing of the trauma (Tinnin, 1994a). In the final phase of treatment the complications of victim mythology and dissociative symptoms are addressed through diverse applications of videotherapy.

Clients are assessed for PTSD, dissociation, alexithymia, and other psychiatric symptomology during intake. If clients present in a regressed state, a regression regimen is applied (see Merroto & Tinnin, 1995). After the client is sufficiently stabilized, T-LTT begins. T-LTT proper utilizes four techniques (which also correspond to phases) for resolving traumatic memories and their sequelae: Video-assisted Trauma Therapy (anamnesis and recursive review); Trauma Art Therapy; Focal Psychotherapy; and Video-dialogue.

Clinical experience suggests that the videotaping may have a greater effect than simply recording the sessions. Patients appear to rapidly assimilate and experience closure to the trauma through the video reviews, art therapy and the use of video-dialogue. Clinical observations suggest that for clients with simple PTSD, effective treatment can usually be completed in 8 - 20 sessions. For clients with complex PTSD, dissociative disorders and/or co-morbid disorders treatment will take longer. The treatment contract is fulfilled when the clients have reported that their PTSD and dissociative symptoms have diminished to a satisfactory level and is reflected in their scores on outcome measures. The client is free to terminate therapy at any time during the treatment trajectory

Summary of the Literature

To date, there has been only one published study using Time-Limited Trauma Therapy (Gentry, 1998). This is a case study of a woman who was a victim of a violent crime, developed PTSD and was treated successfully with T-LTT in eight sessions, showing substantial reductions on all outcome measures (see Table 1). Gentry's (1998) study is a single case report and therefore cannot provide empirical support for the therapy.

Critique

Limitations of Time-Limited Trauma Therapy include (a) the possibility of iatrogenesis with the use of hypnosis/dissociative imagery; (b) it is a complicated procedure that demands high levels of clinical training and skill; (c) it requires technical equipment (video camcorder, TV/VCR, microphone); and (d) it is an experimental procedure without empirical validation.

 

Traumatic Incident Reduction (TIR)

Gerbode (1995) describes a method to inspect, perceive, and understand a traumatic experience stored in memory. This archetype, referred to as Traumatic Incident Reduction (TIR; Gerbode, 1995), requires that the client sequentially go through the experience a number of times. TIR is based on the premise that there is a primary traumatic "root" incident in one’s experience that other subsequent traumatic incidents, or "sequents," are dependent upon (Gerbode, 1995). TIR is a procedure intended to render benign the consequences of past traumatic events (French & Harris, 1998). Case studies suggest that TIR is effective in treating symptoms of Acute Stress Disorder (ASD) and Posttraumatic Stress Disorder (PTSD). The paradigm has elements in common with many other approaches that adopt repetitive exposure and desensitization in mediating traumatic experience, such as sequential analysis and variants of exposure therapy (Bisbey, 1995), and appears similar to prolonged imaginal exposure.

Gerbode (1995) holds that what must be assimilated and accommodated from a traumatic incident are one’s reactions to the incident, including one’s thoughts, sensations, feelings, and perceptions. He further states that in order for any trauma to remain emotionally charged and unresolved, it must remain "uninspected" (p. 436). Trauma symptoms, then, are "powered by" the emotional charge associated with a root incident, one which may be far removed in time from the most recent experience of the symptom (French & Harris, 1998).

Moore (1993) points out that as Pavlov paired the bell with the meat, the repeated paring of one stimulus with another ad infinitum creates a conditioned response chain leading back to the initial conditioned response. He also suggests that the longer the succession of sequents, the less likely it is that a victim will necessarily consciously associate them with the root. That is, the root stimulus can be far enough removed from the present response, that a particular trauma response appears to be more directly affiliated with one or more recent intervening stimuli rather than to the original root traumatic incident. This, explains Moore (1993), is one reason why what he terms covert PTSD symptoms related to an unrecognized or remembered trauma, can be so difficult to treat. In the absence of addressing the root directly, there is always emotional charge available to be triggered. When the client (called a viewer) repeatedly -- in a tightly scripted sequence -- reviews (alternately silently and out loud) a series of incidents or experiences containing unpleasant symptoms, the sequents in effect collapse and the root incident becomes exposed (Gerbode, 1995). This process of reliving and recounting the trauma is similar to exposure therapy. As this occurs, the viewer is allowed to inspect the experience, gain insight into the thoughts, sensations, and feelings suppressed in the original incident, and finally to reach an understanding--an endpoint--of the traumatic experience(s) that is consistent with his or her perception of self and the world (French & Harris, 1998). With the relevant sequents addressed and the root incident eliminated, the viewer can remove the emotional charge. Clinical experience suggests that TIR leads, more often than not, to spontaneously client-generated insight, personal growth, and empowerment (French & Harris, 1998).

Summary of Literature

In her doctoral dissertation, Bisbey (1995) accepted 57 participants diagnosed with PTSD in three separate conditions: Direct Therapeutic Exposure (DTE), which is an exposure treatment that has clients revisit the trauma without strict facilitator directives, TIR, and a control group. Clients in the two treatment groups evidenced significant reductions in trauma symptoms, with TIR showed greater improvements than those who were treated with DTE. Those in the control group did not show significant reductions in symptoms (see Table 1). Bisbey (1995) suggests examining cognitive content as potentially more effective than pure exposure treatments. The Bisbeys’ Partnership in Sussex, England is presently involved in a three-year outcome-research endeavor comparing TIR to DTE, EMDR, and Controls with London Transport employees who had been diagnosed with PTSD following a variety of traumatic events. As of January, 1998, Bisbey (unpublished; personal electronic communication in French & Harris, 1998) reported the crime victims in the treatment groups (42 treated) experienced a significant decrease in trauma-related symptoms as a result of treatment. All subjects qualified for a diagnosis of PTSD at the beginning of the study whereas at the end of the study many did not. Those subjects who received TIR as a treatment assignment improved the most.

Critique

To date, there is no empirical research contained in refereed journals available on the efficacy of TIR, although French & Harris (1998) report informal case studies throughout their text. With the French & Harris (1998) publication, researchers have access to information that should allow outcome research to emanate. Another criticism of TIR has come from the managed care milieu. Because TIR does not conclude until a good endpoint is reached, it does not necessarily conform to the "normal" therapeutic hourly session. As such, managed care appears to be reluctant to authorize the use of a treatment paradigm that could, in one session, take more than 2 hours to complete.

 

Visual-Kinesthetic Dissociation (V/KD)

The Neurolinguistic Programming (NLP) technique of Visual-Kinesthetic Dissociation (V/KD; Bandler & Grinder, 1979; Field, 1990; Konefal, Duncan, & Reese, 1992) assists clients in attaining a degree of kinesthetic dissociation as they visually re-experience their trauma (Hossack & Bentall, 1996), enabling them to process the event(s) from a de-centered perspective. Although NLP has its’ origins in various schools of thought, such as those espoused by Milton Erikson, Virginia Satir, Fritz Perls, Gregory Bateson, and others (Einspruch & Forman, 1985), the actual V/KD procedure itself appears to be a variant of exposure therapy.

According to Koziey and McLeod (1987, p. 278), V/KD was initially used by Erich Fromm, who described the approach as a means of dissociating the “observing ego” from the “experiencing ego.” Bandler extended Fromm’s usage from a 2-point position of displacement (i.e., the observing ego watching the experiencing ego) to a 3-point displacement (i.e., a “higher order” observing ego watching the observing ego watching the experiencing ego; Koziey & McLeod, 1987). Clients are asked to imagine observing themselves (e.g., from the vantage point of a projection booth in a movie theatre) watching themselves (sitting in a theatre seat) re-live their traumatic experience as though in a moving picture (up on the “screen”), while they re-process the event from the safety of the therapeutic setting. As they envision their traumatic experience from the 3-point displacement, they are effectively disconnected from their somatic, spatiotemporal, experiencing ego sensations. They are instructed to metaphorically modulate affective intensity as they proceed through the procedure, through imagery such as “volume control,” “colour options” (e.g., making the picture black and white to decrease affect intensity; making the picture colorful to increase affect intensity; Konefal, Duncan, & Reese, 1992), and so forth.

It is suggested that during V/KD, the traumatically conditioned fear response is replaced, not only with a new set of feelings associated with the visual trauma stimuli, but with more choice/control by the client (Gallo, 1996). Bandler and Grinder (1979) postulate that new sequences (i.e., associations) are formed through the incorporation of new information (for example, more adaptive cognitions) that was not available at the time of the actual event, breaking the previously conditioned chains of response.

Traumatic experiences may be processed by both current and latent mental schemes that ‘compete’ with each other (van der Kolk, McFarlane, & van der Hart, 1996). Direct exposure techniques (such as flooding and live exposure) could result in unmodulated activation of more latent schematic content (e.g., state-dependent abreactions) during re-exposure with some individuals, possibly re-traumatizing them. The literature appears inconclusive in this regard, with some persons showing improvements in symptoms and others showing exacerbation of pre-existing morbidity (e.g., Pitman et al.,1991; Pitman et al., 1996; Watson et al., 1995). The reader is referred to Shalev et al. (1996) for a more complete review.

The guided dissociation process in the V/KD technique may function to assist traumatized individuals in distancing from the distressing affective components of the earlier trauma experience in order to facilitate and maintain more objective contact with current cognitive schemes, thereby aiding in the reprocessing of the trauma by way of current schemata. That is, the separation of cognition and affect in response to the visual stimuli may enable the clients to re-process the trauma through the guided regulation of affect, and to integrate current cognitive resources with latent traumatic schemes. As such, competition between current and latent schemes may be reduced with the V/KD technique such that re-integration can occur with greater efficiency. As postulated by van der Kolk, Burbridge, and Suzuki (1997), intense emotional arousal may prevent the Central Nervous System (CNS) from integrating the traumatic sensory fragments. As such, the lessened affective response that occurs with the V/KD procedure (Field, 1990) may assist the CNS in the integration of previously fragmented traumatic material.

Summary of Literature

Published literature on the V/KD technique is limited to 3 studies (see Table 1). Koziey and McLeod (1987) utilized V/KD in the treatment of 2 female university students who had been raped. Posttraumatic symptoms were assessed both pre- and post-treatment with the Veronen-Kilpatrick Modified Fear Survey (Veronen & Kilpatrick, 1980; Resick et al., 1986) and other indices. Both women showed reductions of at least 1 standard deviation on several scales of the various instruments. Muss (1991) conducted an uncontrolled study with a sample of 19 British police officers who met DSM-III criteria for PTSD and who were treated with V/KD. All participants reported a decrease in intrusive imagery and a return to normal functioning at one-week follow-up. Hossack and Bentall (1996) conducted a study with five males who met DSM-III-R criteria for PTSD following disasters. All five men reported vivid intrusive imagery of death and dying at the initiation of the treatments. Four of the five men showed clear improvements in symptoms and functioning following the procedure.

Critique

Controlled, empirical research is needed to establish the reliability and generalizability of the treatment effect observed in case studies. Some limitations of the V/KD procedure include the following: (a) some clients may have difficulties in obtaining a detached or observer perspective, which will prevent the effective implementation of the procedure and may increase the risk that clients will be retraumatized through the re-experiencing of intense affect; (b) some sessions for strengthening self- and coping-capacities may be required before implementing the V/KD procedure with persons who have limitations in this area; (c) the technique may be less effective with clients chronically traumatized, where there is no one specific traumatic incident for the clients to visualize; (d) it is not clear whether this treatment, or some modification of it, would be effective for symptoms other than intrusive visual imagery, such as ruminations and other intrusive sensory data; and (e) some degree of sensory re-experiencing of the trauma (other than visual) may be necessary for complete integration of the trauma, given that traumatic memories are thought to be stored as sensory fragments in various sensory modalities (Jacobs & Nadel, in press; van der Kolk & Fisler, 1995; van der Kolk, Burbridge, & Suzuki, 1997).

 

Summary of Literature Review

 

Table 1. Summary of the Literature for All Treatments

Note. Effect sizes in bold represent that there was a comparison group, not a wait list comparison.

*CAPS = Clinician Administered Posttraumatic Scale; CR-PTSD = Crime Related PTSD scale; GHQ 30 = General Health Questionnaire; HAD = Hospital Anxiety and Depression scale; IES = Impact of Events Scale; MFS-II = Veronen-Kilpatrick Modified Fear Survey; POMS = Profile of Mood States; SCL-45 = Symptom Checklist 45; SCL-90-R = Symptom Checklist 90-Revised; STAI = State-Trait Anxiety Inventory; TAS = Toronto Alexithymia Scale; TRS = Trauma Recovery Scale (Gentry, 1996)

---------------------------------------

SUMMARY

Description: Eye Movement Desensitization and Reprocessing (EMDR), Thought Field Therapy (TFT), Traumatic Incident Reduction (TIR), Time-Limited Trauma Therapy (T-LTT), and Visual/Kinesthetic Dissociation (V/KD) are utilized frequently in clinical practice for the treatment of Posttraumatic disorders. Although they vary in certain of their dimensions, including variations in treatment procedures, degree of empirical evidence, and the number of practitioners trained in the approaches, desensitization of the traumatic stress symptoms is a major indicator of success, as well as a reprocessing by the client of critical thoughts, feelings, and sensations that covary with the desensitization. The subcommittee assumes that at some future point, the ISTSS Standards of Practice Committee will reconfigure and reorganize the categories based on empirically derived active ingredients. Such distinctions would also contribute to a unified theory of the traumatization process that would promote clinical innovation and treatment outcome research in the field of traumatology.

Strength of Evidence:Recent outcome research on EMDR provides evidence to its greater efficacy in the treatment of PTSD when compared to wait-list controls (Rothbaum, 1997; Wilson, Becker & Tinker, 1995). Although these studies did not control for nonspecific factors such as therapeutic alliance, expectations, or placebo, the studies show strong therapeutic effects. When EMDR is compared to existing treatments for PTSD, the findings are mixed. Of the studies reviewed for this paper, EMDR was found to be significantly superior to relaxation therapy (Carlson et al., 1998), standard clinical care (Marcus et al., 1997), and active listening (Scheck et al., 1998). Boudewyns and Hyer (1996) found that the addition of EMDR or EMDR-plus-eyes-closed to Group Therapy improved treatment outcome when assessed with the POMS, however no differences were found between groups on the CAPS. One limitation of these studies is the lack of established efficacy for standard clinical care, group therapy, and active listening in the treatment of PTSD. When comparing EMDR to exposure therapy combined with skills training (Devilly & Spence, in press), both treatments are found to be effective, with exposure therapy with skills training showing some superiority to EMDR. Limitations of the Devilly and Spence study are that a different measure was used to assess PTSD status at pretreatment and at outcome, the measure that was used at outcome lacks established validity, and Bonferroni corrections were not calculated to control for the myriad of statistical comparisons, thereby increasing the probability that reported effects are overinflated. Other limitations of Devilly and Spence include a lack of conformity to established EMDR procedures, and a 37% drop out rate in the EMDR group. In addition to the limitations noted above, the generalizability to persons with PTSD may be limited in some of these studies, given that not all of the subjects had PTSD prior to treatment (e.g., Scheck, et al., 1998; Wilson, et al., 1995). EMDR is classified as at Level A of the AHCPR criteria.

Although Shapiro (1995) has postulated that the eye movement (or some other external focus) component of the EMDR protocol activates an inherent information processing system, the empirical literature has not provided any conclusive evidence in support of this hypothesis. There is some support for the importance of eye movements (Montgomery & Allyon, 1994; Renfrey & Spates, 1994; D. Wilson et al., 1996); some evidence that eye movements may be no more effective than alternate external stimuli (Devilly et al., 1998; Pitman et al., 1996); and some evidence that no external focus is required (Boudewyns & Hyer, 1996). Methodological limitations of these studies limit the conclusions that may be drawn. To date, the exact mechanism of action in EMDR remains unknown and further study using component analysis is required to clarify this issue.

The clinical evidence for the remaining four approaches is classified by the ISTSS Treatment Guidelines Committee as at Level E of the AHCPR criteria. None of these latter four approaches has included controlled, randomized studies with large enough sample sizes to enable statistical comparisons. Although the TIR study by Bisbey utilized a controlled, randomized design, the study itself has not been subjected to peer review and is thus classified at Level E. The clinical evidence thus far suggests these 4 approaches are promising in terms of effectiveness in the treatment of Posttraumatic disorders.

Course of Treatments: The five approaches covered in this paper are viewed as rapid treatments of simple PTSD, with treatment duration ranging from 1-20 sessions. Some of the approaches require treatment session length that exceeds the typical 50-minute session. The goals of all five treatment approaches are to decrease posttraumatic distress and to re-process and integrate trauma-related material. Treatment duration for complicated PTSD will be greater than for simple PTSD.

Recommendations: It is recommended that practitioners be highly trained in these approaches and in the treatment of PTSD and comorbid disorders before using these approaches in clinical practice and research. Clinicians and researchers should be trained in the assessment and management of dissociation, regression, and posttraumatic abreactions. For clients who present with a high level of dissociation and/or regression, stabilization is of utmost import before implementing the treatment procedures. Clinicians should have, at minimum, graduate level training in the assessment and treatment of psychopathology as well as training in these specific approaches before using them. It is further recommended that training opportunities and literature on various of these approaches be made more readily available to students, clinicians, and researchers.

  Strength of Evidence
Indications  

Intrusive symptoms

A

EMDR

E

TIR; T-LTT; V/KD

 

Avoidant symptoms

 

EMDR

A

TIR; T-LTT

E

Dissociation (T-LTT)

E

Hyperarousal

 

EMDR

A

TIR; T-LTT; TFT; V/KD

E

Alexithymia (T-LTT)

E

Social impairment (V/KD)

E

Occupational impairment (V/KD)

E

Contraindications  

Highly dissociative/regressed (T-LTT; V/KD)

E

Unable to attain observer perspective (T-LTT; V/KD)

E

 

Suggested Readings

Callahan, R.& Callahan, J. (1996). Thought Field Therapy (TFT) and Trauma: Treatment and Theory. Indian Wells, Calif. Callahan Techniques.

French, G. D. & Harris, C. J. (1998). Traumatic Incident Reduction (TIR). Boca Raton: CRC Press.

Hossack, A. & Bentall, R.P. (1996). Elimination of posttraumatic symptomatology by relaxation and Visual-Kinesthetic Dissociation. Journal of Traumatic Stress, 9(1), 99-111.

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

Tinnin, L. (1994). Time-limited trauma therapy. Gargoyle Press: Bruceton Mills,WV

 

AREAS REQUIRING FURTHER EXPLORATION

Establishing the validity of therapeutic efficacy is a relatively recent and clearly timely pursuit. This trend enhances clinician ability to select the most appropriate approaches in the treatment of mental health disturbances. It enables research to inform clinical practice and encourages informed decision making for both client and practitioner. Validating treatment approaches means committing to ongoing research and a dedication to providing the best services possible.

Each of the therapeutic approaches discussed in this paper is a relatively new innovation. EMDR has received the majority of attention at this time and leads the way in terms of published outcome studies. In order to improve the credibility and clinician confidence in these other identified approaches, ongoing research adherence to Task Force (American Psychological Association, Division 12 Task Force, 1995) guidelines for "well-established" treatment is recommended. Specifically, rigorous studies need to be conducted using comparison groups to demonstrate that the identified treatment is equivalent to another “well-established" treatment or superior to medication, psychological placebo or other treatment. Scientist-practitioners are encouraged to take an active role in this line of enquiry using good experimental designs and standardized approaches.

The most important point to consider is the impact that these relatively rapid desensitization approaches will have on clinical work and the potential for a reduction in the length of suffering endured by trauma survivors. The future of the post-trauma treatment field is changing with approaches such as those described in this article paving the way. If it is found that the approaches presented in this article are efficacious based on rigorous research studies, they have the potential to reinvent the manner in which PTSD is treated as well as the long-term prognosis for clients.

It remains our responsibility to empirically validate neoteric approaches that can withstand careful scrutiny and to discard or revise those that fail to maintain standards. In so doing, we become well-informed and able to choose the best for our clients.

Footnotes: 

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