NY Time Article on Evidence Based Treatment

So I’ve been skimming through some stuff I’ve been meaning to read (I’m really behind as you will be able to tell from the date of this article) and came across this gem.

A survey of 200 psychologists published in 2005 found that only 17 percent of them used exposure therapy (a form of C.B.T.) with patients with post-traumatic stress disorder, despite evidence of its effectiveness. In a 2009 Columbia University study, research findings had little influence on whether mental-health providers learned and used new treatments. Far more important was whether a new treatment could be integrated with the therapy the providers were already offering.

The problem is not confined to the United States. Two years ago, Dr. Waller studied C.B.T. therapists in Britain treating adults with eating disorders to see what specific techniques they used. Dr. Waller found that fewer than half did anything remotely like evidence-based C.B.T.

I tend to agree with the opinion that most therapists view their work as more of an art than science. The only real benefit to this belief goes to the therapist’s ego. This view of therapy can also act as a convenient excuse to get lazy and not keep up on the research. The challenge isn’t in having a good relationship with a client it’s in having a good working relationship with a client. The latter requires far more work and is a much greater test of skill.

EMDR,The Weird Therapy

Before I get started with this I feel like I have to talk about the “Little Mermaid”.  That’s right.  I have to play it with my daughter every night. I’m either Sebastian or her father.  I try to be Sebastian as much as I can because that whole relationship with her father is a set-up.

Thanks Disney.

We have Ariel in doll form at every stage of her life (they make a baby Ariel now) and I’ve watched the movie at least three times this year- I watched for the third time last night.

Am I the only person in the world that finds the idea of a half human-half fish mutation repulsive?   The smell alone must be unbearable.  I cannot understand how this whole thing is still sustaining any kind of success.

Alright, so enough of that.

More than a few clients who would and eventually do benefit from EMDR are initially turned off by its “weirdness” and a lot of that usually has to do with their focus on bi-lateral stimulation (BLS)- the whole freaky eye movement thing.

EMDR stands for Eye Movement Desensitization and Reprocessing, it is a form of therapy that is primarily used to treat distress related to a traumatic event.  Given the wealth of research that demonstrates its efficacy and the media attention it received at one point, the questions that many people still hold about EMDR is surprising to me.

Part of the issue is what I believe to be the strange debates around BLS that pop up when someone does a search on EMDR and efficacy.  BLS (right to left/left to right stimulation that is feature of EMDR; takes the form of eye movements, tapping or sound )is  one thing that separates EMDR from other modalities, it’s not the only thing, nor is it the most important. There is no evidence to prove that BLS  works the way the EMDR folks say it does (behind closed doors) but that doesn’t mean EMDR is ineffective or that BLS is not useful. I use BLS because I think it takes the edge off the distress – it can act as a slight and almost soothing distraction for clients during processing. Another reason I use it has to do with the relationship between fidelity to the model and efficacy. This may be surprising to hear since EMDR began with its’ founder (Shapiro) using it as the basis for the model but that bears little relevance to the argument one way or the other.

Saying:

“EMDR works because of BLS and I know this is true because that is how it all started.”

Is as silly as saying:

“EMDR does not work because we have no evidence that BLS is what makes it work.”

When the research suggests EMDR does in fact work but BLS does not appear to be the reason why.

The other aspect that might freak some people out is the floatback which pulls from psychodynamic theory and speaks to the belief within the model that historical events influence current day thinking and reactions.  A significant minority of folks who walk through my the door requesting EMDR confuse it with Recovered Memory Therapy (although they don’t refer to it by name) which is one of many embarrassing chapters in the history of mental health treatment.

The floatback does not seek to recover lost memories, it seeks to work with the memories the client reports while he or she is fully conscious.  If the client struggles with an incomplete memory that drives the distress to the point where EMDR is indicated then EMDR can be used to desensitize the person to the partial memory/thought but it does not  seek to explore its validity or create new memories.

So this brings me to the other criticism of EMDR so succinctly stated by Richard McNally;

What is effective in EMDR is not new, and what is new is not effective. (link)

He is from Harvard, or as they say it – Hawvahd – so he must be right. Right?

Calling EMDR a re-hash of old therapies is like calling DBT a re-hash of CBT. I’ve received formal training in CBT and although DBT pulls from CBT and my understanding of CBT helps me to understand and use DBT skills, I would never call myself a DBT therapist until I was formally trained in it. There are differences that exist in their philosophies, the packaging of the interventions and the language/thinking that is used in applying the interventions.

EMDR is a collection of interventions pulled from several established forms of treatment; its different because it is both eclectic and structured. Its uniqueness and effectiveness probably has more to do with how EMDR understands trauma and its application of these interventions. It demonstrates the same efficacy as CBT and Exposure therapy in treating trauma related distress without the homework and it is more effective than psychoanalysis, psychodynamic therapy or supportive therapy.

Differences, however, don’t just exist in the application of EMDR. One topic that really gets missed in the discussion is the theoretical contribution Shapiro made to the field of trauma work;

All humans are understood to have a physiologically-based information processing system. This can be compared to other body systems, such as digestion in which the body extracts nutrients for health and survival. The information processing system processes the multiple elements of our experiences and stores memories in an accessible and useful form. Memories are linked in networks that contain related thoughts, images, emotions, and sensations. Learning occurs when new associations are forged with material already stored in memory.

When a traumatic or very negative event occurs, information processing may be incomplete, perhaps because strong negative feelings or dissociation interfere with information processing. This prevents the forging of connections with more adaptive information that is held in other memory networks. For example, a rape survivor may “know” that rapists are responsible for their crimes, but this information does not connect with her feeling that she is to blame for the attack. The memory is then dysfunctionally stored without appropriate associative connections and with many elements still unprocessed. When the individual thinks about the trauma, or when the memory is triggered by similar situations, the person may feel like she is reliving it, or may experience strong emotions and physical sensations. A prime example is the intrusive thoughts, emotional disturbance, and negative self-referencing beliefs of posttraumatic stress disorder (PTSD).

It is not only major traumatic events, or “large-T Traumas” that can cause psychological disturbance. Sometimes a relatively minor event from childhood, such as being teased by one’s peers or disparaged by one’s parent, may not be adequately processed. Such “small-t traumas” can result in personality problems and become the basis of current dysfunctional reactions.

Shapiro proposes that EMDR can assist to successfully alleviate clinical complaints by processing the components of the contributing distressing memories. These can be memories of either small-t or large-T traumas. Information processing is thought to occur when the targeted memory is linked with other more adaptive information. Learning then takes place, and the experience is stored with appropriate emotions, able to appropriately guide the person in the future. (link)

As a culture I understand we have walked away from using theory as a credible argument for legitimacy (which has become problematic but material for another time); yet the theory is a match to the model and the model works.

Like other treatment modalities, EMDR pulls from other schools of thought in its thinking and application. Like other modalities there are pieces of it that we know work and parts of it we think might work but cannot yet reasonably demonstrate whether they really do work, how they work and/or why they work. We do know that, as a whole, EMDR is highly effective in treating complicated trauma and as a result of the research conducted on its efficacy, groups like the APA and VA have thrown strong support behind its use as one of three preferred methods of treating it. EMDR is also safe; the initial stages of EMDR seek to assess the appropriateness of the intervention for clients (both in terms of potential vulnerability and responsiveness); has formal protocols in place for grounding and de-escalation and contains the active work around the trauma to the session. This does not mean EMDR is right for everyone (some folks don’t respond and others respond poorly); like I said, this fact is formally acknowledged in the protocol which seeks to identify candidacy issues before any processing taking place.

So stop calling it weird.

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You’re making it feel bad.

Okay…what I just did there was weird.

But that makes me weird (which you probably already guessed was true), not EMDR.