These two articles and one reply explore the implications of using the controversial treatment for posttraumatic stress responses with children. I would be interested in hearing what other people think about this issue. See my addresses on the Index page.
In 1987, a psychology graduate student named Francine Shapiro noticed that her own upsetting thoughts faded when her eyes spontaneously moved rapidly from side to side. Two years later, she published a controlled study on "eye movement desensitization," which described a dramatic single-session cure for 22 PTSD subjects (Shapiro, 1989a, 1989b). Results were maintained at 3-year follow-up, at which time Shapiro (1991a) stated that her method was more complex than she initially realized (adding the "reprocessing"), and required formal, supervised training for maximum effect and client safety (Shapiro, 1991b).
Eye movement desensitization and reprocessing (EMDR) is a complex method which combines elements of behavioral and client- centered approaches. Briefly, the procedure involves having the client concentrate intensely on the most distressing segment of a traumatic memory while moving the eyes rapidly from side to side (by following the therapist's fingers moving across the visual field). Following the initial focus on the memory segment, after each "set" of eye movements (of about 30 seconds), the client is asked to report anything that "came up," whether an image, thought, emotion, or physical sensation (all are common). The focus of the next set is determined by the client's changing status. For example, if the client reports, "Now I'm feeling more anger," the therapist may suggest concentrating on the anger in the next set. The procedure is repeated until the client reports no further distress and can fully embrace a positive reframe.
The advent of EMDR has generated an enormous amount of excitement as well as controversy. The excitement was fueled by a series of case reports which were similar to Shapiro's initial findings, as well as some controlled studies (for a review, see Greenwald, 1994a) which were initially known primarily by those who were trained in EMDR and who attended limited-access meetings. Confusion was engendered by the widespread publication of substandard material, by researchers who were untrained in EMDR and did not recognize the importance of following Shapiro's revised protocol. The controversy, partially based on bad data, was fueled by concern that EMDR's increasing popularity was premature, and by objections to Shapiro's insistence on a preliminary period of sole-source training (e.g., Acierno, Hersen, Van Hasselt, Tremont, & Meuser, 1994). (This controversy is discussed in detail in Greenwald, 1996.)
EMDR has recently entered a new phase. A number of studies have established EMDR as a highly efficacious treatment for traumatic memories (e.g., Carlson, Chemtob, Rusnak, Hedlund, & Muraoka, 1995; Grainger, Levin, Allen-Byrd, & Fulcher, 1994; Silver, Brooks, & Obenchain, 1995; Vaughan, Armstrong, Gold, O'Connor, Jenneke, & Tarrier, 1994; Wilson, Becker, & Tinker, 1995; see also Greenwald, 1994a, 1996, and Shapiro, 1995 reviews). The publication of an EMDR textbook (Shapiro, 1995) marks the end of sole-source training. And, although Shapiro's organization will continue to offer training and community service, an independent organization is being founded to develop training and practice standards and to sponsor conferences and a journal.
EMDR has rather suddenly become the most effective and most extensively researched treatment for PTSD. Additional applications are also being explored, including treatment of anxiety, depression, unresolved grief, addictions, dissociative disorders, and other conditions (see Greenwald, 1994a; Shapiro, 1995). In general, the approach is to facilitate the working- through of "stuck" material, but some approaches also incorporate EMDR's apparent enhancement effect on learning. To date, this range of applications has not been tested in controlled studies.
EMDR's applicability to the treatment of traumatized children appears to be quite promising. Case reports are positive and consistent with findings on similar treatment of adults, except that child treatment may be even more rapid (e.g., Cocco & Sharpe, 1993; Greenwald, 1993, 1994b; Pellicer, 1993; Shapiro, 1991a). Completion of a number of controlled group studies on EMDR with children can be expected within the coming year (Editor's note: this was written in early 1996). If current impressions are confirmed, the impact on children's psychological development and quality of life may be profound (Greenwald, 1995b).
At present, the EMDR treatment of traumatized children must be considered experimental (like other methods). Hundreds of clinicians are already using EMDR with children, while others await further evidence. This is, of course, a personal decision. Those who do choose to use EMDR are urged to obtain formal, supervised training (see Greenwald, 1994a); those using EMDR with children are further urged to study Greenwald's (1993) handbook. Finally, it should be emphasized that EMDR should only be used by fully qualified psychotherapists, within the context of a comprehensive treatment plan.
-- Ricky Greenwald, Psy.D. Correspondence regarding this
article may be addressed to : Ricky Greenwald, Psy.D., 483 Belknap Rd., Framingham, MA 01701 USA.
Acierno, R. Hersen, M., Van Hasselt, V.B., Tremont, G., & Meuser, K.T. (1994). Review of the validation and dissemination of eye-movement desensitization and reprocessing: A scientific and ethical dilemma. Clinical Psychology Review, 14, 287-299.
Carlson, J.G., Chemtob, C.M., Rusnak, K., Hedlund, N.L., & Muraoko, M.Y. (June, 1995). EMDR in combat-related PTSD: A controlled study. Paper presented at the EMDR international conference, Santa Monica, CA.
Cocco, N., & Sharpe, L. (1993). An auditory variant of eye movement desensitization in a case of childhood post-traumatic stress disorder. Journal of Behavior Therapy and Experimental Psychiatry, 24, 373-377.
Grainger, R.D., Levin, C., Allen-Byrd, L., & Fulcher, G. (August, 1994). Treatment project to evaluate the efficacy of eye movement desensitization and reprocessing (EMDR) for survivors of a recent disaster. Presented at the American Psychological Association annual convention, Los Angeles, CA.
Greenwald, R. (1993). Using EMDR with children. Available from EMDR, P.O. Box 51010, Pacific Grove, CA 93950-6010 with formal training.
Greenwald, R. (1994a). Eye movement desensitization and reprocessing (EMDR): An overview. Journal of Contemporary Psychotherapy, 24, 15-34.
Greenwald, R. (1994b). Applying eye movement desensitization and reprocessing (EMDR) to the treatment of traumatized children: Five case studies. Anxiety Disorders Practice Journal, 1, 83-97.
Greenwald, R. (1996). The information gap in the EMDR controversy. Professional Psychology: Research and Practice, 27, 67-72.
Greenwald, R. (1995b). Children's mental health care in the 21st century: Eliminating the trauma burden. Manuscript submitted for publication.
Pellicer, X. (1993). Eye movement desensitization treatment of a child's nightmares: A case report. Journal of Behavior Therapy and Experimental Psychiatry, 24, 73-75.
Shapiro, F. (1989a). Efficacy of the eye movement desensitization procedure in the treatment of traumatic memories. Journal of Traumatic Stress, 2, 199-223.
Shapiro, F. (1989b). Eye movement desensitization: A new treatment for post-traumatic stress disorder. Journal of Behavior Therapy and Experimental Psychiatry, 20, 211-217.
Shapiro, F. (1991a). Eye movement desensitization and reprocessing procedure: From EMD to EMD/R -- A new treatment model for anxiety and related traumata. The Behavior Therapist, 14, 133-135, 128.
Shapiro, F. (1991b). Eye movement desensitization and reprocessing procedure: A cautionary note. The Behavior Therapist, 14, 188.
Shapiro, F. (1995). Eye movement desensitization and reprocessing: Basic principles, protocols and procedures. New York: Guilford Press.
Silver, S.M., Brooks, A., & Obenchain, J. (1995). Treatment of Vietnam war veterans with PTSD: A comparison of eye movement desensitization and reprocessing, biofeedback, and relaxation training. Journal of Traumatic Stress, 8, 337-342.
Vaughan, K., Armstrong, M.S., Gold, R., O'Connor, N., Jenneke, W., & Tarrier, N. (1994). A trial of eye movement desensitization compared to image habituation training and applied muscle relaxation in post-traumatic stress disorder. Journal of Behavior Therapy and Experimental Psychiatry, 25, 283-291.
Wilson, S.A., Becker, L.A., & Tinker, R.H. (1995). Eye movement desensitization and reprocessing (EMDR) treatment for psychological traumatized individuals. Journal of Consulting and Clinical Psychology, 63, 928-937.
The theme of the November, 1995, national conference of the International Society for Traumatic Stress Studies (ISTSS), was the treatment of PTSD. My impression coming out of the conference was that we are far from understanding how to effectively treat posttraumatic stress responses. This appears to be particularly true for traumatized children (for sexually abused children, anyway, whose treatment has been studied more than that for other traumatized kids, and even that not much; see Finkelhor & Berliner, 1995, for a review of research in this area).
I do not know if it is frustration with this state of affairs, or if other issues are involved related to the desire to relieve the obvious pain of traumatized people (and relieve our own secondary traumatization as well, perhaps), but there appears to be a growing tendency among clinicians to renounce the more traditional therapies in favor of new, purportedly "quick cures," such as EMDR.
I myself am ambivalent about the effectiveness of EMDR. It would certainly be wonderful if EMDR did provide quick, lasting relief for traumatized individuals. But, despite claims by EMDR advocates to the contrary, not enough trustworthy evidence has been collected yet, especially when the approach is used with children, to allow me to decide one way or the other. Unfortunately, as Finkelhor and Berliner (1995) point out, we do not have much trustworthy evidence yet about the effectiveness of any method of treating childhood PTSD.
Ricky Greenwald has provided an optimistic introduction to EMDR above (see also Greenwald, 1994a, 1994b). Like other advocates of the approach, he clearly believes that its effectiveness has been repeatedly demonstrated. To get a different perspective, let us review some of the critiques that have been made of the EMDR research and the technique itself. Most of the points I make here have been made in two critical reviews (Herbert & Mueser, 1992; Lohr et al., 1992) and one critical commentary (Metter & Michelson, 1993), and I will not take up space by referencing them as I list the arguments. Some EMDR advocates (including Greenwald, 1992b) have acknowledged some of these criticisms as warranted (while arguing against others, of course). I will not try to cover every argument and counter-argument here. I simply wish to point out some of the reasons for caution when considering whether or not to use EMDR to treat a traumatized child.
1) EMDR advocates make the claim that it is the most frequently studied treatment for PTSD. This may or may not be the case, but if it is, it may testify more to our inadequate research efforts on treatment issues in general than to the effectiveness of EMDR. Furthermore, the majority of the so- called EMDR efficacy research is seriously flawed methodologically.
Standardized measures have rarely been used, and when they have, contrary to the claims of many EMDR advocates, the results have frequently been either mixed or negative (see Greenwald, 1994b, for a fairly well-balanced review). Most researchers have primarily relied on Subjective Units of Disturbance scales (SUDS), which are subjective self-reports of discomfort with the memories being "processed" and are therefore open to biased reporting.
Other methodological problems abound. For example, subjects in the EMDR condition in Shapiro's first study (1989a) were required to continue in each session of EMDR treatment until their SUDS were in the "0" or "1" (low anxiety) levels, effectively placing an experimental demand on the subjects. Compounding the problem in this study was the fact that this condition was not enforced in the "control" group. Most studies, too, have been conducted by the author(s) of the research, introducing the possibility of unintentional experimenter bias. Finally, the diagnostic status of subjects has rarely been considered in published analyses.
2) Extravagant claims are put forth about the efficacy of the treatment. In one of the first published papers on EMDR, Shapiro (1989a) asserted that "the evidence clearly indicates that a single session of the EMD procedure is effective in desensitizing memories of traumatic incidents and changing the subjects' cognitive assessments of their individual situations." Research has not born out that conclusion, especially when chronic trauma is involved (Greenwald, 1994b). Moreover, the technique has recently been put forward as something of a panacea for a wide variety of other problems, "such as anxiety disorder other than PTSD, personality disorders, multiple personality and other dissociative disorders, and the problems of adult children of alcoholics" (noted by Herbert & Mueser, 1992), as well as "depression, unresolved grief, addictions" (see Greenwald, above). It is unclear why the technique should be supposed to be effective for all of these problems.
Advocates also claim that EMDR can be used not only to "unblock" traumatized memories1, but to "install" positive cognition as well. Thus, while describing how EMDR appeared to reduce negative cognition regarding one subject's perceived inferior status with her husband, Shapiro (1991a) reported, "She was then asked to imagine herself interacting with him easily and comfortably. She reported feeling progressively more 'em-powered' as the eye movements were continued" (1p. 135). This is not the same as removing negative memories, or even increasing positive memories. This is a purported creation of a new cognition. (In fact, it sounds like hypnosis.) How does this fit in with the EMDR method?
3) There is no acceptable theoretical basis to EMDR. Shapiro (e.g., 1989a, 1991a) has put forth several possibilities but acknowledges that all of them are only of heuristic value at the moment. The one that appears most plausible suggests that "the eye movements used in EMD/R may be the body's natural inhibitory mechanism, similar or identical to the 'rapid eye movement' (REM) dream state of sleep, during which unconscious material surfaces and may be desensitized and integrated" (Shapiro, 1991a, p. 135). I have to admit that I find this theory a bit shaky, but some investigators have begun to investigate it, so relevant data may begin to emerge soon. But right now we do not know what, if anything, happens when a trained clinician asks a client to concentrate on a traumatic imagery and its attendant feelings while focusing on the rhythmic back-and-forth movements of the clinician's finger in front of the client's eyes.
Greenwald (1994b) suggests that EMDR may be effective primarily with people who have suffered an acute rather than chronic traumatization. He furthermore suggests that because EMDR is designed to address specific memories one at a time, its effectiveness may be limited to those memories "processed" during treatment rather than to the full spectrum of experienced symptoms. At least this is a more reasonable and defensible position than the more extravagant claims put forth by other EMDR advocates.
4) The fact that we have no idea about what EMDR really does for traumatized people is very problematic. The commentary by Metter and Michelson (1993) should be read by anyone considering adopting the technique, especially with children. they document several troubling concerns.
They note, for example, that "EMDR has much in common with 'sequence disruption' techniques that alter clients' perception of selected feelings by interrupting how they are experienced" (p. 413). The back-and-forth finger may convey a subtle "no" or "stop that" message to the client. "This produces an initial subjective change which is then exploited by the therapist using a series of reframings and manipulated expectancies" (p. 413). They suggest that physical eye strain may be experienced as punishing; clients may be induced to agree with the therapist in order to escape this pain. The possible demand characteristics of the technique are particularly worrisome if they are to be applied to traumatized children, especially when the traumas are of an enduring or abusive nature.
5) What if EMDR is, at least in part, a hypnotic induction technique? Does that mean that clients who receive the treatment are "programmed" to report what the clinician wants them to report? I know of a least one adult who said he did not remember what happened during the therapy. How true is this of most patients? It would make an interesting study to test whether or not EMDR was more effective with clients who were highly hypnotizable. Even more troublesome is the possibility that EMDR may encourage dissociative experiences. Perhaps this is why some patients report reduced subjective anxieties and/or report that they can no longer remember the traumatic memory that was troubling them. Too many advocates seem to feel that forgetting the experience is a good outcome. I would prefer the client remember it but in a new, less threatening context.
6) Other concerns voiced by Metter and Michelson (1993) have to do with the lack of pacing and depth associated with the therapeutic process. Some clinicians may also be inclined to rely solely on EMDR. Greenwald (above) suggests that it should be only one tool in a therapist's anti-PTSD arsenal.
1. Am I the only one who is reminded by EMDR of L. Ron
Hubbard's pseudopsychiatry, Dianetics (later to become
Scientology)? In this approach, traumatic experiences from the
past ("engrams") are "cleared" with the assistance of a modified
lie-detector (the "e-meter"). Dianetics, too, was
initially embraced enthusiastically by many in the psychiatric
community as an effective therapy.
Finkelhor, D., & Berliner, L. (1995). Research on the treatment of sexually abused children: A review and recommendations. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 1408-1423.
Hebert, J.D., & Muesser, K.T. (1992). Eye movement desensitization: A critique of the evidence. Journal of Behavior and Experimental Psychiatry, 23, 169-174.
Lohr, J.M., Kleinknecht, R.A., Conley, A.T., Del Cerro, S, Schmidt, J, & Sontag, M.E. (1992). A methodological critique of the current status of eye movement desensitization (EMD). Journal of Behavior and Experimental Psychiatry, 23, 159-167.
Metter, J., & Michelson, L.K. (1993). Theoretical, clinical, research, and ethical constraints of the eye movement desensitization reprocessing technique. Journal of Traumatic Stress, 6, 413-415.
In the second issue of The CHILD SURVIVOR of Traumatic Stress, I wrote an optimistic introduction to eye movement desensitization and reprocessing (EMDR) (Greenwald, see above), and Ken Fletcher wrote a cautionary response (Fletcher, see above). I want to respond to some his comments, and provide an update on recent developments.
I will first note that I was pleased with the tone of the exchange. Apparently, EMDR supporters are sometimes perceived as cultist fanatics, and EMDR opponents are sometimes perceived as closeminded reactionaries. It is refreshing to participate in a more calm and reasoned discussion on this topic.
I would like to correct a number of misconceptions. In Fletcher's defense, he is not an expert on EMDR, and was presenting apparently reasonable concerns based on critiques published in respected journals. These concerns are probably shared by many responsible professionals, and I am glad to have the opportunity to address them in this forum.
In my earlier review (Greenwald, 1994), I did not suggest that EMDR is only effective with single-trauma PTSD. Rather, I stated that such cases have the most documentation of treatment effect, probably because research is easiest to complete due to the brevity of treatment required. Furthermore, the full spectrum of related symptoms typically is resolved following EMDR treatment of single-trauma PTSD. However, when only one of many traumatic memories is treated, the full spectrum of symptoms is likely to remain, fueled by the untreated memories.
The comments inspired by Metter and Michelson (1993) seem to reflect a lack of understanding of what actually occurs in an EMDR session. EMDR is quite distinct from hypnosis, procedurally and phenomenologically as well as physiologically (Nicosia, 1995; Wilson, Covi, & Foster, 1993). And far from encouraging dissociation as feared, the core function of EMDR is to facilitate integration (E.G., Nicosia, 1994; Paulsen, 1995). This integration happens step by step, as in some other types of therapy; in EMDR, the steps happen to be comparatively rapid. The application of EMDR to an apparently wide variety of disorders is due to its function of integrating "stuck" material such as traumatic memories. Those of us in the traumatic stress field understand that traumatic memories can contribute to a variety of disorders, including PTSD, anxiety, depression, etc. It is not surprising that a treatment for traumatic memories could contribute to resolution of these problems.
It should be emphasized that integration is not merely desensitization, catharsis, or insight, but a comprehensive working-through that can encompass any of these functions. Although patients may occasionally state that they later "forgot" the memory, upon questioning it turns out that the memory is simply not pressing upon consciousness as it had before, that now it is part of the past. Patients also typically show greater comfort in discussing the memory, as well as a healthier perspective on it (thus the adaptive reframe, or positive self- statement).
Fletcher's overall stance was to advocate caution, citing two excellent reviews (Herbert & Musser, 1992; Lohr et al., 1992) which pointed to the lack of quality data available some years ago. However, most of the concerns they listed have been resolved by later, more sophisticated studies, including the five recent ones I have cited. Thus, our so-called conversation was at cross-purposes, since we were working from entirely different sets of data. This "information gap" is, unfortunately, all too common in discussions about EMDR, and has been addressed at length in Greenwald (1996a). There are still real questions about EMDR, including underlying mechanism, theoretical "home," scope of effect, and range of application. By now there is little doubt as to EMDR's effectiveness for adults with single- trauma PTSD, and its use with chronic trauma is promising.
EMDR for children and adolescents has progressed just a bit beyond anecdotal support. One study of institutionalized sex- offender adolescents found that three EMDR sessions led to decreased disturbance, increased sense of cognitive control, and increased empathy for the victim (Datta, 1996). Another study of children and adolescents treated for a single trauma found that 17 or 20 achieved partial or complete resolution of symptoms after a single EMDR session (Puffer & Greenwald, 1996). These unpublished studies lack sophistication, but it's a start. Two major studies are currently in the works. We are also continuing to develop and test protocols for specialized applications, and to refine standards of training and practice. Of course, it would be premature to advocate EMDR's use with children, and this remains a personal decision for each clinician. Formal, supervised training is critical for client safety and optimal treatment effect (Greenwald, 1996).
In conclusion, I wholeheartedly support skepticism, especially
when vulnerable children are at stake. However, this skepticism
should not be allowed to interfere with objective examination of
the data. I would especially recommend perusing the most recent
description (Shapiro, 1995), reviews (e.g., Greenwald, 1996) and
studies (e.g., Wilson, Becker, & Tinker, 1995). And I predict
that those who do inform themselves of EMDR's current status,
with due objectivity, will find it hard to avoid feeling at least
a little optimism.
Nicosia, G. (1995). Eye movement desensitization and reprocessing is not hypnosis. Dissociation, 8, 69.
Paulsen, S. (1995). Eye movement desensitization and reprocessing: Its cautious use in the dissociative disorders. Dissociation, 8, 32-44.
Puffer, M.K., & Greenwald, R. (1996). A controlled study of eye movement desensitization and reprocessing (EMDR) with traumatized children and adolescents. Manuscript submitted for publication.
Wilson, D.L., Covi, W.G., & Foster, S. (1993). Eye movement desensitization and reprocessing: Effectiveness and automatic correlates. Paper presented at the EMDR Annual Conference, San Jose, CA.
I, too, appreciate Ricky Greenwald's willingness to take part in this extremely important debate. After reading his reply to my Cautionary article, I look forward to some day reading some of the more recent publications he cites. Until I do, however, I feel it incumbent upon me to continue to urge caution in the use of EMDR with children, as, I am pleased to see, does Greenwald in his reply. I too would recommend take very close, critical looks at the current literature, what there is of it. As you can see, I am not as enthusiastic about the current references Greenwald cites, but I would like to read them. I will try to obtain copies (perhaps from Ricky himself) and review them in a later issue of the newsletter. For now, I would just like to note that it is not enough to assert something to make it true. I need to see proof that EMDR is "quite distinct from hypnosis" (per Greenwald's reply and Nicosia, 1995), that there is little or nothing to fear about its relation to dissociative experiences, or that it facilitates integration of "stuck" material (and I would like to know more about what that is supposed to mean, as well). Even if it does somehow facilitate the integration of so- called "stuck" material (again, I associate this with the assertions of Dianetics [see footnote to my article above]), I still do not understand how this would help people with personality disorders or addictions, among other problems advocates have suggested it can help. I would also like to point out that I still am concerned about people who do not remember the treatment itself -- immediately after receiving treatment. Nor do I understand how new cognition can be created. Finally, I am not yet convinced that EMDR research has become all that much more methodologically sophisticated. I guess I'll have to try to take a closer look at the most current research. After I do, I'll report back to you. But meanwhile, if you are considering using this treatment, I would recommend you take a close, critical look at the literature as well, both pro and con.
As of January, 1998, Ricky Greenwald tells me that Chemtob and colleagues are currently conducting a controlled study of the effectiveness of EMDR among kids traumatized by a hurricane. And a group in Colorado Springs have conducted a study on kids with PTSD in the public school system. I know that Bessel van der Kolk is also studying the effectiveness of EMDR among traumatized kids. So it looks like we may be getting more information on the subject sometime in the near future.
For more information on EMDR and kids, you can check out Ricky Greenwald's web page.
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