EMDR as mesmerism as anything else ...

This is an article by Gerald Rosen, PhD that was first printed in the Journal of Anxiety Disorders.

Journal of Anxiety Disorders, 1999, 13, 173-184

Treatment Fidelity and Research on
Eye Movement Desensitization and Reprocessing (EMDR)

Gerald M. Rosen, Ph.D.
Independent Practice, Seattle, Washington

Abstract

Eye Movement Desensitization and Reprocessing was introduced by F. Shapiro (1989) as a treatment for posttraumatic stress disorder. When controlled studies failed to support the extraordinarily positive findings and claims made by Shapiro, proponents of EMDR raised the issue of treatment fidelity and criticized researchers for being inadequately trained. This paper considers the issues raised by EMDR proponents. It is concluded that treatment fidelity has been used as a specious, distracting issue that permits the continued promotion of EMDR in the face of negative empirical findings. Clinical psychologists are urged to remember the basic tenets of science when evaluating extraordinary claims made for novel techniques.

Eye Movement Desensitization was initially advanced as a treatment for posttraumatic stress disorder, although its clinical applications have been extended considerably over the years. Initial reports on EMD (Shapiro, 1989), and subsequent case reports on an extended method known as Eye Movement Desensitization and Reprocessing (see Shapiro, 1995) generated substantial interest among psychologists, such that over 25 outcome studies on the effectiveness of EMDR have been published in peer review journals (see Lohr et al, 1995, 1998). Shapiro, the originator of EMD and EMDR, is correct when she states that no other treatment for PTSD has received this amount of attention.

Unfortunately, controlled studies have not replicated the extremely positive, if not amazing clinical results claimed in Shapiro's original study. In that study, 100% of 22 individuals with traumatic memories reportedly demonstrated significant reductions in anxiety toward those memories. Further, the majority of these individuals were reported to have experienced a total elimination or substantial decrease in associated symptoms such as nightmares or intrusive thoughts. In contrast to these extraordinary findings, most published studies have reported modest results, and several studies have failed to support any role for eye movements, the very procedural component that most distinguishes EMDR from other exposure based therapies (see Lohr et al., 1998). Such findings have left most reviewers of the literature less than excited about EMDR (Acierno et al., 1994 ; DeBell & Jones, 1997; Foa & Meadows, 1997; Herbert & Mueser, 1992; Keane, in press; Lilienfeld, 1996; Lohr et al., 1995, 1998).

Proponents of EMDR have responded to these empirical findings by criticizing the training of those conducting research and raising concerns of "treatment fidelity." Shapiro (1995; 1996 a,b) and Greenwald (1994 a,b; 1996) have advanced this argument in several publications. Greenwald (1996) suggested that negative findings on EMDR result from an information gap between, "those who have and those who have not undergone the formal, supervised training provided by Shapiro's EMDR Institute." (p. 67) Shapiro (1995) has stated: "Researchers should be trained in the entire EMDR methodology....Clearly, methods used incorrectly or incompetently by researchers contribute little or nothing to the knowledge base about these methods and, indeed, can lead to false conclusions." (p. 325) In a recent correspondence to promote the EMDR International Association (EMDRIA), Shapiro stated: "The only studies of EMDR showing no effect are those with insufficient checks of fidelity to treatment."

THE NEED FOR TREATMENT FIDELITY IN OUTCOME RESEARCH
"Fidelity" is a strong word, charged with meaning, and suggestive of important responsibilities and commitments. It is a word used in many contexts, one of which includes a therapist's adherence to the proper administration of a treatment procedure. Interest in treatment fidelity has increased in recent years. When Billingsley and colleagues (1980) reviewed 108 treatment outcome studies published in the late 1970's, they found that only 5.6% of studies assessed treatment implementation. Ten years later, Moncher & Prinz (1991) considered 359 outcome studies and found that 45% had attended to the issue of treatment fidelity. Further, there was a significant increase over the course of the decade in the percentage of studies that considered the issue of treatment adherence. While this was a positive trend, Moncher and Prinz emphasized the need for greater attention to the matter of treatment fidelity.

Previous authors writing on the issue of treatment fidelity have occasionally failed to state several basic points. For example, treatment fidelity must be defined and measured in a manner that is independent of treatment outcome. At the same time, the notion that a therapist should be faithful to a particular treatment procedure assumes that the procedure is effective and treatment outcome relates to specific procedural ingredients. Without these conditions, treatment fidelity is a moot point. There also is the issue of whether a particular treatment is "robust." Thus, some treatments require precision of method, and treatment fidelity is critical to successful outcome; in other cases, a treatment approach, no matter how broadly applied, can serve its purpose. It follows from these points that measures of treatment fidelity need not correlate with measures of treatment outcome if the treatment is ineffective, or conversely, if the treatment is highly effective and robust. Issues of treatment effectiveness, procedural specificity, and robustness are matters to be determined empirically, not by a clinician's experience or beliefs.

Moncher and Prinz (1991) point out that treatment fidelity refers to two distinct issues, which they call treatment integrity and treatment differentiation. They note that one must consider both issues, since treatments can be found to differ when not implemented as intended (integrity), or conversely, treatments may be administered with high integrity, but not be sufficiently distinct (differentiation). One can appreciate the many logical combinations of factors that result from such distinctions.

It is in the context of these issues, that Shapiro (1995; 1996 a, b) and Greenwald (1994 a,b; 1996) have raised potentially valid concerns with regard to whether or not researchers have been faithful to the EMDR method. In effect, Shapiro and Greenwald are proposing that EMDR is effective; that there are critical procedural components to which one must faithfully adhere; and treatment effects, though powerful, are not so robust that violations in procedural integrity can be ignored.

TREATMENT FIDELITY AND EMDR: WHO'S BEEN UNFAITHFUL?
It is important to set the issue of treatment fidelity in the context of EMDR's short history. When Shapiro (1989) first reported on the apparently spectacular effects of what was then called Eye Movement Desensitization, she had the following to say about treatment fidelity, required training, and probable outcome: Since the present study represents the seminal work on the EMD technique, as much information as possible has been included regarding the procedure for purposes of study replication and further investigation. However, it should be emphasized that more detailed explanations may be necessary in order for other experimenters/therapists to achieve the 100% success-rate revealed in this study. Every attempt has been made to standardize the procedure....Therefore, the author is convinced that enough information has been given here to achieve complete desensitization of 75-80% of any individually treated trauma-related memory in a single 50-min session. (p. 221)

Shapiro's assessment constitutes a rather remarkable statement, one that was contradicted by her own subsequent recommendations in 1990 when formal training was recommended to learn the EMD method. This formal training initially consisted of a two day workshop, after which a participant received a Certificate of Completion. However, by 1991, Eye Movement Desensitization had become Eye Movement Desensitization and Reprocessing and training had expanded, such that Level I yielded only a Certificate of Attendance, and a second two day workshop (Level II) was required for the Certificate of Completion. In the short span of just two years, Shapiro had gone from her 1989 statement to a much more elaborate model. These changes all occurred in the context of clinical "experience," without any data to show that Level II training yielded better results. Despite this absence of data, clinicians were told that using EMDR without appropriate training could be dangerous, and completion of authorized workshops became the minimum standard.

Shapiro's first response to published findings negative to EMDR occurred in a debate with Metter and Michelson in the Journal of Traumatic Stress. Metter and Michelson (1993) reported that Shapiro had demonstrated EMDR with two clients and both of these clients found the procedure unpleasant and ineffective. These authors further noted that they, and a dozen other professionals who attended Shapiro's training seminar, also found EMDR to be ineffective with a wide range of disorders. Metter and Michelson concluded: "In summary, we recommend extreme caution in embracing, using or endorsing EMDR. Indeed, it is unethical and a stated violation of APA professional guidelines to make sensationalistic claims for unproven interventions, particularly with a touted "one-session" cure," (p. 415).

Shapiro's (1993) response to Metter and Michelson centered on the issue of treatment procedures, training, and treatment fidelity. She stated: "...although trained by me, their EMDR workshop was only the second one that I had taught in this country, the first occurring the day previous. At that time I was making a number of assumptions about what I needed to teach that I have since modified....current (italics provided by Shapiro) trainings emphasize client-safety factors and specifically address the recognition of individual differences in the areas of rapport, pacing, expectation...Two years ago, I did not realize that it was necessary to teach specific guidelines regarding these factors," (p. 417). Shapiro concluded with the observation, "EMDR is not a 'simple technique,' as I had once thought when my first articles were published...In fact, clients can be at risk if untrained clinicians attempt EMDR," (p. 420). One can observe that Shapiro's response to Metter and Michelson never addressed the treatment failures attributed to her, nor was Shapiro responsive to an apparent discrepancy between "one-session cures," claimed at the workshop, and the reality of the participants' findings. Further, Shapiro advanced the perplexing paradox that clinicians she trained were "untrained." Despite these logical problems in her response, Shapiro's exchange with Metter and Michelson established the argument that negative findings were the fault of clinicians and their training, rather than a critical problem with EMDR.

The theme of inadequately trained clinicians again arose in an exchange between Greenwald (1994 b) and Sanderson and Carpenter (1994). These latter authors had conducted a study (Sanderson & Carpenter, 1992) in which imaginal exposure to feared objects was either accompanied by eye movements or eyes closed and motionless. They conducted the study to test a very specific hypothesis set forth by Shapiro (1989): The primary component of the EMD procedure is the generation of rhythmic, multi-saccadic eye movements while the client concentrates on the memory to be desensitized. (p. 201) Both treatment groups in Sanderson and Carpenter (1992) had reduced anxiety ratings, leading the authors to conclude: "...the benefits of EMD, at least in phobics, bear no relation to eye movements." (p. 275). Greenwald (1994 b) took the authors to task for using EMDR without any training other than the procedural descriptions provided by Shapiro's 1989 article. This criticism is without substance since Shapiro (1989) specifically stated that upwards of 80% of clients could be treated successfully if clinicians relied on her written description. Greenwald further criticized Sanders and Carpenter for using an inadequate control condition and for violating Shapiro's description of EMDR. Sanderson and Carpenter (1994) rejoined that their EMDR and control conditions were well suited to test whether eye movements were a primary component of the EMDR method. Greenwald's comments on issues of training and treatment fidelity were rejected, and the role of eye movements remained unsupported.

It did not take long for additional negative findings to appear. Jensen (1994) investigated EMDR with 25 Vietnam combat veterans. The study was a serious effort to provide a fair test of EMDR and replicate Shapiro's original findings: it included a no treatment control group; subjects who received EMDR had two treatment sessions; therapists attended the two day workshop then offered by Shapiro; therapists also practiced EMDR to assure familiarity with procedures; and standardized PTSD measures were employed. Jensen found that EMDR was effective in reducing in-session subjective anxiety, but was not effective in improving PTSD symptoms. Jensen noted that his findings were similar to those of Boudewyns et al. (1993), whose subjects also generally failed to show improvement on PTSD measures.

Jensen reported that an independent observer watched video taped sessions to assess treatment fidelity. The observer noted that, "...clients may have received enough treatment to open difficult areas, but without enough fidelity to the treatment to resolve these problems," (p. 321). It is unclear if this comment by the observer refered to the need for more treatment sessions, or the need for each session to be extended until such time as anxiety reduction occurred. Either way, the observer's comment confused the matter of treatment success with the issue of treatment fidelity. As regards within-session fidelity, some confusion of concepts may be inherent in the procedural demands of the method. Thus, EMDR requires repeated sets of eye movements until the patient lowers subjective ratings of distress (SUDS); this might suggest that if a session ends without improvement, then EMDR was not conducted faithfully. Of course, such an argument leads to an untenable basis for defining treatment fidelity; if this is what the observer was suggesting, it was incumbent upon him to specify indices of treatment fidelity that were independent of outcome.

Jensen was generous in his subsequent discussion of EMDR. He suggested that therapists more experienced with the technique might yield better effects, an untested argument in line with Shapiro's views. Despite apparent problems in the observer's interpretation of fidelity issues, Jensen remained open to the observer's comment, accepted Shapiro's 1989 findings as a standard, and stated: "...increased standardization in training, and in the EMD/R procedure itself, appears necessary for therapists in the field to approach the efficacy in using EMD/R reported by Shapiro." (p. 322).

Shapiro's (1996a) response to Jensen's even-handed treatment of his data was to misrepresent his position and report: "Jensen stated in his own article that he was known to have misapplied the procedure.....Jensen (1994) received only half of the standard basic training...Such a lack of concern for standards of validity- both by the researcher and the published research reviewers- do a great disservice to the profession," (pp. 3-4). Actually, Jensen never said he misapplied the procedure, and there is no evidence that he did. Evidently, Shapiro makes the same error of logic that was noted for the observer, by confusing treatment outcome and length of therapy with treatment fidelity. Further, Jensen was generous in offering two full treatment sessions when one considers that Shapiro (1989) claimed cure rates of 100% in a single session. When Jensen's therapists completed a full two day training workshop from Shapiro herself, they achieved a level of training far greater than what Shapiro (1989) originally stated would be needed. Also, at the time Jensen ran his study, only Level I training was required for the official Certificate of Completion. Jensen (personal communication, February 20, 1998) was kind enough to provide this author with a copy of his certificate dated December 15, 1990. That certificate was accompanied by a letter signed by Francine Shapiro. Portions of that letter are cited below:

Enclosed please find the Certificate of Completion for the two-day basic training course in EMD/R. You are among the very select group of mental health professionals who chose to be trained in this procedure in the first year it was offered in the United States. This Certificate is being issued because we feel very strongly that the integrity of EMD/R can be protected only if it is in the hands of trained (underlining by Shapiro) professionals...We consider this an ethical issue and will be writing and speaking of it more in the future. Therefore, we hope you will find the Certificate useful and will distribute the enclosed flyer to talented clinicians with whom you would like to share this information...Once again, thank you for your participation, vision, and desire to heal.

All points considered, Jensen's study was a competent attempt to assess EMDR as it was then known; the findings from the study were clear, and Shapiro's (1989) original claims were not supported. In return for this research effort and self-critical analysis of findings, Jensen was accused of being half trained, lacking of sufficient concern for standards, and performing a disservice to the profession. An alternative view, of course, is that Shapiro's unwarranted attack of Jensen represents an abuse of the treatment fidelity issue.

A researcher's level of training has not been the only basis for attacking findings negative to EMDR. Consider, for example, a study by one of the leading researchers in the area of Posttraumatic Stress Disorder, Roger Pitman (Pitman et al., 1996). In this study therapists received both Level I and Level II training workshops to learn the EMDR method. Pitman and his colleagues compared EMDR with and without the eye movement component, in a crossover design with Vietnam veterans. In the "eye fixed" condition, the patient tapped his fingers to control for activity during the EMDR procedure. This study tested whether eye movements were a primary component of the EMDR method, the same hypothesis addressed by Sanderson and Carpenter (1992).

Pitman found that both treatment conditions produced modest to moderate improvement on such measures as the Impact of Event Scale, and there was no meaningful effect associated with eye movements. These findings, of course, presented a problem for EMDR, a relatively new and novel method that had proclaimed a critical role for eye movements. After all, without the "E" and the "M", one is left with already established therapeutic components, namely "D" for desensitization, and "R" for cognitive reprocessing. In that case specialized training by the EMDR Institute would be no more indicated than any other training in the broadly defined field of cognitive and behavioral therapies.

Sometime around or shortly after the collection of data in the Pitman study, Shapiro began to recommend the use of alternate tapping strategies. For example, Shapiro (1993) reported that, "EMDR trainings presently include instruction on the selected use of certain kinds of hand-taps and auditory signals in addition to eye movements." (p. 420) This same theme has continued in subsequent publications (Shapiro, 1994, 1995). Thus, instead of the therapist producing sets of saccades by waving fingers in front of a patient's face, a therapist can snap fingers, or tap on the patient's knees. In fact, a therapist can use the very type of finger tapping Pitman had chosen for a control condition. In other words, by this twist of procedural logic, Pitman and his colleagues had simply compared EMDR to itself! This is exactly what Greenwald (1996) concluded when he noted that Pitman's findings are frequently cited, "..... as an example of EMDR's failure to outperform an alternate treatment, when in fact only variants of EMDR itself were compared." This argument, of course, represents an absurd abuse of the treatment differentiation issue raised by Moncher & Prinz (1991). As with Jensen, the rules for testing EMDR were changed so that a testable hypothesis at point A became irrelevant at point B. Fortunately, Pitman's response to Greenwald's analysis could not have been more to the point: "Scientific theories are meaningless if they are not falsifiable." (Pitman et al., 1996, p. 426)

Even when researchers are Level II trained, use control treatments with no alternate tapping methods, and follow specific treatment protocols outlined by Shapiro, they can still be accused of violating treatment fidelity when findings fail to support EMDR. Muris and colleagues (1998) conducted a study on the treatment of specific phobias. The therapist in this study completed Level I and II workshops, and the treatment protocol for specific phobias (Shapiro, 1995) was carefully followed. Twenty-six children with fear of spiders received EMDR, in-vivo exposure, or a computerized exposure control condition. Results clearly favored in-vivo exposure and EMDR was judged to be of limited value.

How have these recently published findings been received by proponents of EMDR? A discussion on the treatment of specific phobias occurred among members of the EMDR electronic mail list just weeks after the Muris article was sent to journal subscribers (emdr@maelstrom.stjohns.edu, February, 1998). The names of several individuals who participated in the discussion would be recognized by those familiar with the literature on EMDR.1 One of these individuals noted that in-vivo exposure involves real practice with spiders, while EMDR does not; this observation led the psychologist to ask if a behavioral assessment of phobic avoidance was an "honest" way to compare the two methods. It was noted that the researcher/therapist in Muris et al. (1998), though Level II trained in EMDR, only had experience with subjects in previous studies. This therapist also was associated with a University, but was not a licensed clinician; the question was asked, was this "ethical?" Another psychologist commented that academicians are too concerned about data while EMDR therapists, and clinicians in general, care about helping people. Yet a third recognized psychologist noted that Muris and colleagues had used the protocol for specific phobia, and the question was raised if some or most spider phobics really require the protocol for "process" phobias. "Protocols" are specific procedural steps recommended for particular disorders; in the present case, this involved Shapiro's empirically untested distinction between specific and process phobias. Confusing the matter further was the fact that spider phobia was always considered to be a specific phobia (see Shapiro, 1995), at least up to the time of the present discussion on Muris' negative findings. The list members continued their focus on this issue of specific vs process protocols and it was concluded that, for most studies on specific phobias, "researchers were either untrained in the method, used only a restricted number of directed eye movements, or inaccurately implemented the procedure." It also was observed that, "In all studies the full phobia protocol was not applied." And so we learn from this most recent discussion that fully trained researchers who follow recommended protocols can still end up unfaithful to EMDR.

As it turns out, one need go no further than Shapiro's (1989) original study to see how treatment fidelity concepts have been misused in the service of EMDR. Shapiro (1996b) reviewed controlled PTSD research evaluating EMDR and listed in table format, "all studies in which the investigators had received training in the use of EMDR....All investigators who relied on the 1989 articles to study "EMD" are excluded, whether or not their results supported that procedure (which is considerably less complex than EMDR)." (p. 214, parentheses provided by Shapiro). Given these decision rules, one can ask why Shapiro's original 1989 study appears in the table with a fidelity rating of, "high." What possible decision rule for rating treatment fidelity could lead to a "high" rating for Shapiro's study, a "low rating for the Level I trained therapists in Jensen's study, and a "variable" rating for the Level II trained therapists in Pitman's study? The only answer that occurs to this writer is that Shapiro has once again confused the issue of treatment fidelity with treatment outcome. It also is most unclear why EMD is portrayed as inferior to EMDR when no study subsequent to Shapiro (1989) has matched the spectacular findings found in that original report. Why, it can be asked, must one receive Level II training and be faithful to the various protocols of a more "complex" EMDR, when all of these improvements have never been able to match the original findings? No answer occurs to this writer in response to that question.

THE VOWS THAT BIND: KEEPING FAITHFUL TO SCIENCE
The short but eventful history of EMDR has captured the attention of psychologists who work in the area of Posttraumatic Stress and other anxiety disorders. Unfortunately, it often is difficult to comprehend what is fact and what is fiction. Nevertheless, several points are quite clear after nearly a decade of studying EMDR. First, no controlled study has replicated the extraordinary single session findings originally reported by Shapiro (1989). Second, the majority of studies that control for eye movements indicate an absence of effect from this procedural element. Third, EMDR has gone through more than one metamorphosis, and training requirements have shifted with nearly equal frequency. Given these findings, the basic conditions for appealing to treatment fidelity have not been met. Simply put, there is no clear set of effective procedures to which one must be faithful.

DeBell and Jones (1997) carefully reviewed the extant literature on EMDR and came to a number of sobering observations relevant to any clinician who uses EMDR. DeBell and Jones quoted the following from Shapiro's 1995 text:

.....clinical observation suggests that therapists trained formally or through supervision by experienced EMDR clinicians can expect a high success rate (perhaps as much as 80-90%) for appropriately selected clients. If this level of success is not being achieved, the clinician should take responsibility for becoming more skilled in the method. (p. 339)

It is instructive to compare this statement with Shapiro's 1989 proclamation provided earlier in this paper. DeBell and Jones commented in their review that controlled research, rather than "clinical observation" would provide Shapiro with a stronger basis for the claims advanced on behalf of EMDR. They observed that Shapiro places blame on the clinician if EMDR is not effective, a rather bold position to take for a relatively new procedure. DeBell and Jones took note of the changes Shapiro has made in EMDR procedures, such that eye movements are no longer unique in producing therapeutic effects. They commented on the contradiction that then occurs when Shapiro criticizes earlier studies for not following the original eye movement protocols. And, they stated with great insight, "What, exactly, is required for this technique and how do we evaluate research outcomes? With so many sanctioned variations, one begins to wonder whether EMDR is standardizable...future researchers will be challenged to find alternatives for comparative research that Shapiro and her followers will not criticize as a type of bonafide EMDR."(p. 161)

Proponents of EMDR are not playing fair with science (Rosen & Lohr, 1997) if they insist on treatment fidelity for the induction of eye movements, then state that alternate tapping strategies are possible, next argue that various protocols must be followed, and then switch the decision rules for these protocols. Without supporting data, Shapiro, Greenwald, and others can not proclaim that Level II training is required, when once upon a time, Level I training was sufficient, and, before then, simple written descriptions sufficed. Proponents of EMDR also are in error when they confuse the issue of treatment fidelity with the measurement of treatment outcome. The methods of EMDR must be specified in such a manner that falsifiable hypotheses can be tested, and measures of treatment fidelity must be defined independent of how patients progress in treatment.

The issue of treatment fidelity has been raised in many therapy studies with genuine concern (Moncher & Prinz, 1991; Waltz et al., 1993). At the same time, treatment fidelity is an issue that can be abused and misused to defend against negative findings: in the case of EMDR, it appears this has happened. Clinicians are dealing with a slippery slope, one where the rules keep changing, and data can never catch up. They can participate in these developments and employ the methods of EMDR if they wish, but they do so at some risk. One day, clinicians may find themselves in front of reasonable fellow citizens, having to explain why they waved fingers in front of a patient's face, when studies failed to support the miraculous claims made in the late 1980's by the founder of EMDR. When that moment comes, a clinician who opines that published studies lacked fidelity is unlikely to prevail.

REFERENCES:

Acierno, R. Hersen, M., Van Hasselt, V.B., Tremont, G. & Mueser, 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.

Billingsley, F., White, O.R., & Munson, R. (1980). Procedural reliability: A rationale and an example. Behavioral Assessment. 2, 229-241.

Boudewyns, P.A., Stwertka, S.A., Hyer, L.A., Albrecht, J.W., & Sperr, E.V. (1993). Eye movement desensitization for PTSD of combat: A treatment outcome pilot study. the Behavior Therapist, 16, 29-33.

DeBell, C. & Jones, R.D. (1997). As good as it seems? A review of EMDR experimental research. Professional Psychology: Research and Practice. 28, 153-163.

Foa, E.B. & Meadows, E. A. (1997). Psychosocial treatments for posttraumatic stress disorder: A critical review. Annual Review of Psychology, 48, 449-480.

Greenwald, R. (1994a). Eye movement desensitization and reprocessing (EMDR): An overview. Journal of Contemporary Psychotherapy. 24, 15-34. Greenwald, R. (1994b). Criticisms of Sanderson and Carpenter's study on eye movement desensitization. Journal of Behavior Therapy and Experimental Psychiatry. 25, 90-91.

Greenwald, R. (1996). The information gap in the EMDR controversy. Professional Psychology: Research and Practice, 27, 67-72. Herbert, J.D. & Mueser, K.T. (1995). Eye movement desensitization: A critique of the evidence. Journal of Behavior Therapy and Experimental Psychiatry, 23, 169-174.

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.

Keane, T.M. (1998). Psychological and behavioral treatments of posttraumatic stress disorder. In P.E. Nathan & J.M. Gorman (Ed). A guide to treatments that work (pp. 398-407). New York: Oxford University Press.

Lilienfeld, S.O. (1996). EMDR treatment: Less than meets the eye? Skeptical Inquirer, January/February, 25-31.

Lohr, J.M., Kleinknecht, R.A., Tolin, D.F., & Barret, R.H. (1995). The empirical status of the clinical application of eye movement desensitization and reprocessing. Journal of Behavior Therapy and Experimental Psychiatry, 26, 285-302.

Lohr, J.M., Tolin, D.F., & Lilienfeld, S.O. (1998). Efficacy of Eye Movement Desensitization and Reprocessing: Implications for behavior therapy. Behavior Therapy, 29, 123-156.

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.

Moncher, F.J., & Prinz, R.J. (1991). Treatment fidelity in outcome studies. Clinical Psychology Review, 11, 247-266.

Muris, P., Merckelbach, H, Holdrinet, I, & Sijsenaar, M. (1998). Treating phobic children: Effects of EMDR versus exposure. Journal of Consulting and Clinical Psychology, 66, 193-198.

Pittman, R.K., Orr, S.P., Altman, B, Longpre, R.E., Poire, R.E., & Macklin, M.L. (1996). Emotional processing during eye movement desensitization and reprocessing therapy of Vietnam veterans with chronic posttraumatic stress disorder. Comprehensive Psychiatry, 37, 419-429.

Rosen, G.M. & Lohr, J.M. (1997). Can eye movements cure mental ailments? National Council Against Health Fraud Newsletter, 20, 3.

Sanderson, A. & Carpenter, R. (1992). Eye movement desensitization versus image confrontation: A single-session crossover study of 58 phobic subjects. Journal of Behavior Therapy and Experimental Psychiatry. 23, 269-275.

Sanderson, A. & Carpenter, R. (1994). Criticisms of Sanderson and Carpenter's study on eye movement desensitization: Rejoinder. Journal of Behavior Therapy and Experimental Psychiatry. 25, 91.

Shapiro, F. (1989). Efficacy of the eye movement desensitization procedure in the treatment of traumatic memories. Journal of Traumatic Stress, 2, 199-223.

Shapiro, F. (1993). Eye movement desensitization and reprocessing (EMDR) in 1992. Journal of Traumatic Stress. 6, 417-421.

Shapiro, F. (1994). Alternative stimuli in the use of EMDR(R). Journal of Behavior Therapy and Experimental Psychiatry. 25, 89.

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

Shapiro, F. (1996a). Errors of context and review of eye movement desensitization and reprocessing research. Journal of Behavior Therapy and Experimental Psychiatry. 27, 1-5.

Shapiro, F. (1996b). Eye movement desensitization and reprocessing (EMDR): Evaluation of controlled PTSD research. Journal of Behavior Therapy and Experimental Psychiatry. 27, 209-218.

Waltz, J., Addis, M.E., Koerner, K. & Jacobson, N.S. (1993). Testing the integrity of a psychotherapy protocol: Assessment of adherence and competence. Journal of Consulting and Clinical Psychology, 61, 620-630.

FOOTNOTES

1. List members were not contacted to request permission to identify them by name. Therefore, no specific identities are provided in this discussion. The reader can access messages by contacting LISTSERV@MAELSTROM.STJOHNS.EDU and signing on with the statement, "subscribe EMDR firstname lastname." At the present time, only individuals with Level I and/or Level II training from the EMDR Institute, Inc. can join the list. If this presents a problem for a reader interested in the original messages, please contact me and I will ask the list moderator if arrangements can be made.

DECombs@attbi.com