|
||
| Greenwald, R. (in press). The power of suggestion: Comment on EMDR and Mesmerism: A comparative historical analysis (McNally, in press). Journal of Anxiety Disorders. | ||
| Correspondence concerning this article should be addressed to Ricky Greenwald, Psy.D., P.O. Box 575, Trumansburg, NY 14886, USA. Electronic mail may be sent via Internet to rickygr@childtrauman.com | ||
| I found Dr. McNally's (in press) comparison of EMDR and Mesmerism both interesting and educational, but ultimately disappointing. Instead of fully realizing the promise of illuminating underlying social principles to explain these apparently similar phenomena, a secondary agenda took precedence: presiding over EMDR's "death by innuendo." I would like to raise concerns regarding the innuendo approach, and to respond with substantive comments on key issues. | ||
| I am taking the unusual step of addressing McNally's stylistic approach because so much of his message is contained therein. Apparently not one to underestimate the power of suggestion, McNally flung barb upon barb against EMDR without ever actually spelling out his message. He suggested, in essence and by implication, that the EMDR movement has been fueled more by charismatic leadership and other social forces than by substance or empirical evidence. Unfortunately, the death-by-innuendo strategy mimics the very tactics of the persuasion style about which he is expressing justifiable concern. I would prefer that critics of a Mesmerism-like movement challenge the method's credibility by presenting real data in a straightforward manner, and by applying scientific criteria as per contemporary standards. | ||
| The unstated anti-EMDR agenda was pursued, often at cross-purposes to the primary theme of historical comparison, throughout the paper. The campaign began in the second paragraph of the introduction, by citing only Shapiro (1996a) as a reviewer favorable to EMDR (omitting, among others, Feske, 1998; Greenwald, 1994, 1996; Lee, Gavriel, & Richards, 1996; Van Etten & Taylor, 1998), while listing a veritable army of reviewers "less impressed" by EMDR. This skewed name-dropping strategy creates the false impression of Shapiro as a lone figure battling the legions of wisdom and science. Later, this was reinforced through subtle ridicule, for example, by citing a book entitled, "Crazy Therapies" to list some contents of Shapiro's (1995) text, instead of citing Shapiro directly. He was even able to find a mention on the Internet, from one of the 25,000+ EMDR-trained clinicians, of EMDR being used to treat the trauma of an alien abduction! | ||
| Alien abductions aside, there is at least a reasonable explanation for the application of EMDR to such a wide range of disorders, within the context of an appropriate treatment plan. In treating traumatic memories, the hypothesized "accelerated information processing" effect (Shapiro, 1995) is viewed as facilitating the processing to resolution of previously "stuck" material, resulting in elimination of post-traumatic stress and related symptoms. EMDR may offer similar utility in a wide range of disorders in which incompletely processed upsetting memories may contribute to symptom formation. For example, a loss may lead to depression, and a fright may lead to phobia; both may be amenable to treatment with EMDR by targeting the incompletely processed source memory. Asthmatics may reduce attack frequency by resolving traumatic memories and reducing their reactivity and stress level. Children with learning disabilities may gain confidence and persistence once EMDR has been applied to their accumulation of frustration-related memories. EMDR's effect on traumatic memories may apply to the full range of severity of upsetting memories, and regardless of the memory-related symptomatic manifestations. In other words, EMDR may be used to treat an underlying element common to many disorders. | ||
| McNally also took pains to point out instances in which Shapiro or others allegedly misrepresented a professional organization's stance regarding EMDR. Although such concerns should be addressed, this paper was probably the wrong venue, as there was no parallel example of misrepresentation offered for Mesmer. Instead, it seemed calculated to discredit Shapiro - and EMDR by association - and to isolate her from the professional community. My goal is not to debate Shapiro's conduct here, but to point out further evidence of the sub-text of the paper. Indeed, the paper is laced with ridicule, sarcasm, and one-sided portrayal of various points designed to impugn EMDR, regardless of availability of parallels with Mesmerism. | ||
| Substantive issues were also settled by innuendo, primarily regarding treatment fidelity and efficacy, which are closely related. First, treatment fidelity concerns were neatly disposed of by falsely characterizing the EMDR protocol as "protean," too slippery to pin down. This is simply a red herring. For example, the option of using alternative modes of bilateral stimulation, in lieu of eye movements, has been part of the protocol for most of EMDR's history; it was not new when I was trained in 1992, and it has been noted repeatedly in the literature. Yet, some persist in expressing shock at this variation, as if it had just been produced from a magician's hat. Although the EMDR protocol is indeed multi-faceted and includes a number of choice points, the protocol is also quite well defined and readily available, both in print (Shapiro, 1995) and at workshops. Furthermore, since EMD became EMDR (Shapiro, 1991), the basic protocol has undergone hardly any modification. (Some variants have been developed for specialized applications; for example, the protocol is simplified for use with young children.) There is no mystery here, no excuse for feigned confusion. I have never heard of a qualified fidelity rater who has had any difficulty in identifying elements of a session as being consistent with, or divergent from, the specified protocol. | ||
| Later in the paper, the fidelity issue was summarily decided against EMDR, by declaring McGuinn's (1997) rebuttal to one expression of such concerns to be "swift and effective." It is inexplicable that the importance of treatment fidelity should be minimized or dismissed, selectively for EMDR, within portions of the scientific community. There is considerable evidence to support the notion that treatment fidelity is related to outcome in EMDR research, and there is some indication that extant training practices are not always sufficient to ensure fidelity (Greenwald, 1996). Proper evaluation of EMDR, or any method, relies on the assurance that the method is actually being tested. This is why ensuring treatment fidelity is recognized as a "gold standard" component of treatment outcome research (Foa & Meadows, 1997). | ||
| Consideration of treatment fidelity is central to the disputed validity of EMDR studies with negative findings, perhaps the biggest bone of contention in the efficacy debate. McNally's historical comparison may be quite relevant in this regard. Although Mesmer's theory of animal magnetism was disproved, his concerns regarding treatment fidelity were arguably legitimate. Mesmerism was debunked as relying on the "power of suggestion," yet it is now celebrated for exactly that reason. In other words, the method was legitimate in utilizing this powerful psychological force for healing, even though Mesmer's own explanations, and some of the trappings of his method, were ultimately discarded. If Mesmer had been allowed to maintain treatment fidelity during the preliminary experimental evaluation of his method, Mesmerism might indeed have fared better. Instead, because respected scientists selected ostensibly key components of the method which, in isolation, fared poorly, the baby was thrown out with the bath-water. | ||
| McNally celebrated the process by which Mesmerism was discredited, even while acknowledging Mesmer as a forefather of hypnosis, a respected branch of mental health practice with extensive empirical support. This strikes me as contradictory. Would it not have been preferable to first test the treatment as a whole, before trashing it when isolated parts were found wanting? Might not the effective components of Mesmerism have been thereby recognized, utilized and further developed much sooner? Ben Franklin et al's elegant experiments were indeed useful for exposing Mesmer's theory as invalid; however, the eminent scientists apparently failed to consider that the method itself might have been valid regardless. According to my reading of McNally's paper, the debunking of Mesmerism was misguided and unfortunate. | ||
| A similar ill-advised movement is afoot with EMDR when, contrary to the advice of EMDR experts, researchers alter or omit elements of the protocol, or use unqualified therapists, and then use their findings as evidence against EMDR. For example, some critics believe that testing the effects of eye movements can determine the validity of the treatment as a whole (Richard J. McNally, personal communication, August 13, 1998). This would be reminiscent of the animal magnetism experiments. It is inappropriate to use unqualified therapists, protocol alterations, and/or dismantling studies to draw initial efficacy conclusions, because treatment fidelity has almost certainly been violated. Rather, every effort should be made to ensure treatment fidelity while testing the protocol under a variety of controlled conditions. Once EMDR has gained recognition as a viable treatment, then component analyses should certainly be conducted, to learn more about the method, its components, and its underlying mechanisms. | ||
| McNally concluded by implying that the APA committee on empirically validated treatments (Chambless et al, 1998) may have used overly lax standards in recognizing EMDR, and that the more stringent and desirable criteria of Franklin et al might send EMDR the way of Mesmerism. Shapiro (1998), on the other hand, recently protested that the same APA committee was overly harsh towards EMDR, by failing to differentiate between flawed and well-designed studies. She stated, for example, that additional controlled studies supportive of EMDR were "canceled out" by the equal weighting of studies such as Jensen's (1994), in which the author himself acknowledged inadequate fidelity. The chair of the APA committee in question (Dianne Chambless, personal communication, August 9, 1998) noted that the designation of EMDR's status was made on the basis of more supportive evidence than that reported by McNally. She was less specific regarding the fidelity issue, simply indicating that the committee had taken "the entire body of literature into account." | ||
| Mesmerism was prematurely rejected because the scientific community failed to sufficiently value treatment fidelity. This error was compounded by confounding dismantling and component analysis with treatment efficacy. One can only regret that the development of hypnosis was thereby delayed. Now some elements in the scientific community are attempting the same error with EMDR. Considering the accumulation of positive findings with EMDR in controlled studies, as well as critical analyses relating positive findings to treatment fidelity (Greenwald, 1996; Lee, Gavriel, & Richards, 1996; Shapiro, 1996b), even those who remain skeptical of EMDR must acknowledge the possibility that treatment fidelity concerns are as pertinent to EMDR as to other methods. On the chance that EMDR offers even some of the benefits claimed by proponents, it would be a tragedy to send EMDR the way of Mesmerism on the basis of suggestion, innuendo, and bad science. Certainly we should be able to agree on conducting a scientifically appropriate evaluation. | ||
| References | ||
| Chambless, D.L, Baker, M., Baucom, D., Beutler, L., Calhoun, K., Crits-Christoph, P., Daiuto, A., DeRubeis, R., Detweiler, J., Haaga, D., Bennett Johnson, S., McCurry, S., Mueser, K., Pope, K., Sanderson, W., Shoham, V., Stickle, T., Williams, D. and Woody, S. (1998). Update on empirically validated therapies, II. The Clinical Psychologist, 51, 3-16. | ||
| Foa, E. B. & Meadows, E. A. (1997). Psychosocial treatments for posttraumatic stress disorder: A critical review. Annual Review of Psychology, 48, 449-480. | ||
| Feske, U. (1998). Eye movement desensitization and reprocessing treatment for posttraumatic stress disorder. Clinical Psychology: Science and Practice, 5, 171-181. | ||
| Greenwald, R. (1994). Eye movement desensitization and reprocessing (EMDR): An overview. Journal of Contemporary Psychotherapy, 24, 15-34. | ||
| Greenwald, R. (1996). The information gap in the EMDR controversy. Professional Psychology: Research and Practice, 27, 67-72. | ||
| Jensen, J. A. (1994). An investigation of eye movement desensitization and reprocessing (EMD/R) as a treatment for posttraumatic stress disorder (PTSD) symptoms of Vietnam combat veterans. Behavior Therapy, 25, 311-325. | ||
| Lee, C. W., Gavriel, H., & Richards, J. (1996). Eye movement desensitisation: Past research, complexities, and future directions. Australian Psychologist, 31(3), 168-173. | ||
| McGlynn, F. D. (1997). Response to Lipke's comment. Journal of Anxiety Disorders, 11, 599-602. | ||
| McNally, R. (in press). EMDR and Mesmerism: A comparative historical analysis. Journal of Anxiety Disorders. | ||
| Shapiro, F. (1991). 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. (1995). Eye movement desensitization and reprocessing: Basic principles, protocols and procedures. New York: Guilford Press. | ||
| Shapiro, F. (1996a). Eye movement desensitization and reprocessing (EMDR): Evaluation of controlled PTSD research. Journal of Behavior Therapy and Experimental Psychiatry, 27, 209-218. | ||
| Shapiro, F. (1996b). Errors of context and review of eye movement desensitization and reprocessing research. Journal of Behavior Therapy and Experimental Psychiatry, 27, 313-317. | ||
| Shapiro, F. (1998, July). Riding the wave. Keynote address presented at the annual meeting of the EMDR International Association, Baltimore. | ||
| van Etten, M. & Taylor, S. (1998). Comparative efficacy of treatments for posttraumatic stress disorder: A meta-analysis. Clinical Psychology and Psychotherapy, 5, 126-145. | ||
| DECombs@attbi.com | ||
