APA EMDR Evaluation

Recently the American Psychological Association compiled yet another (see the Overview of EMDR at this site for others) evaluation of the research for methods of treating PTSD. Their work, based on previous work by another organization, placed EMDR in the “suggested” rather than the higher, “recommended”, category. The meeting during which the final report was ratified was summarized on the APA Division 56 (Trauma Psychology) discussion list. Below, in italics, is a quote from that summary, followed by my posted comment, which includes a link to a much more thorough and erudite response to the discussion list.

“Even before the meeting took place both of us began to hear there was discontent with the guidelines from certain constituencies – in particular from advocates of EMDR, who were displeased that it had only received a “second-tier” endorsement, and from Div39, who felt that the process had totally ignored empirical evidence which they believe supports the value of psychodynamic approaches in the treatment of PTSD.”

“Those EMDR advocates, always complaining about their level of endorsement, while others nobly object to the way evidence was handled. When the committee called for responses, why didn’t the EMDR folks point out problems with the guidelines, such as the way the important Wilson et al (1997) study was handled? Oh wait, they did. Letters to the committee included discussion of the Wilson paper, whose positive results for EMDR were excluded because all subjects did not meet full PTSD criteria. However, the APA committee ignored the fact that the when the Wilson study considered the results of the 32 subjects who met full criteria, those subjects improved as much as those who did not meet full criteria. (Interestingly an IOM review made the same mistake and also ignored it’s being called to that committee’s attention.) A letter with an extensive critique sent by Dominguez and Lee is a available at http://dx.doi.org/10.4225/23/583ba82e129b9

Finally, on the subject of clinical practice and EMDR: I’d like to suggest that given the research on EMDR and other methods, the finding that EMDR shows very rapid positive results for some clients and that it incorporates key features of CBT, it makes sense to offer clients who are ready for intensive trauma work EMDR first, and then if it is not successful, other methods. For clients who are not ready for intensive trauma work, non-exposure aspects of CBT would be a good choice to begin, then progress to EMDR. Of course, some therapist would prefer to progress to PE.

Thanks for your attention,

Howard Lipke”

Wilson, S., Becker, L.A., & Tinker, R.H. (1997). Fifteen-month follow-up of eye movement desensitization and reprocessing (EMDR) treatment of post-traumatic stress disorder and psychological trauma. Journal of Consulting and Clinical Psychology, 65, 1047-1056.

Comment of Litz et al. and Moral Injury Parts 1 & 2

Part 1

In their influential discussion of the psychological effects of war, Litz et al. (2009) offer the term “moral injury” to describe the destructive effects of the moral and ethical challenges (that is, horrors) of war. That they are raising the subject to academics, many of whom consider the emotional problems related to trauma essentially fear based, is a valuable service. They also usefully summarize research on the effects of moral conflict and violation of life principles on warriors. So, perhaps it will be considered quibbling if I raise a few concerns about their presentation, nonetheless:

1. Litz et al. assert that since DSMIII “there has been very little attention paid to the lasting impact of moral conflict-colored psychological trauma among war veterans in the clinical science community.” If by “the clinical science community” they mean non-practicing clinicians, they might be right, however,

2. when they go on, in their Introduction, to say that:

“A possible reason for the scant attention is that clinicians and researchers who work with service members and veterans focus most of their attention on the impact of life-threat trauma, failing to pay sufficient attention to the impact of events with moral and ethical implications; events that provoke shame and guilt may not be assessed or targeted sufficiently. This explanation seems plausible given the emphasis on fear memories in evidence-based models of treatment…”

it looks to me as if they are demonstrating their lack of knowledge about the work practicing clinicians actually do with combat veteran clients. The clinicians I have known, over my 35+ year career working with combat veterans in a VA treatment center and in providing consultation to therapist in many VA treatment centers, have continually tried mightily to help veterans with profound destructive non-fear related emotions.

Litz et al. offer no support for their claim about how clinicians act in this matter, but, as the above quote indicated they do offer speculative reasons why this imaginary phenomena might have “occurred”. Their assertion in the above quote that clinicians have been attending primarily to fear based emotions because they are influenced by evidence based methods appears to dismiss years of evidence cited by Karlin and Cross ( 2014), VA colleagues of Litz et al., who conclude that evidence based methods have been practiced in research settings and “…have not crossed the bridge into community practice settings in public and private mental health care systems.” (p19)

3. In their review of the clinical practices available for treating “moral injury” Litz et al. erroneously find no evidence based methods that explicitly address this issue. This failure appears to be inexplicable ignorance of EMDR, one of the few widely accepted evidence based treatments for PTSD ( e.g. VA/DoD, ISTSS guidelines), and one that explicitly acknowledges the non-fear based psychologically destructive effects of war and other traumatic experience. It is inexplicable, because this group of authors have certainly been aware of EMDR and its scientific standing.

Very early in Shapiro’s development of EMDR she conceptualized one source of distress as related to how clients held themselves responsible for events, whether or not they were reasonably to blame. So, in the cognitive therapy like (actually, it seems most specifically similar to, but not the same as, Ellis’ REBT) portion of EMDR treatment, she had clients develop what might become an understanding of the events and their regretted behavior that would conceivably not be associated with debilitating level of emotions, such as guilt, shame or despair they feel ( e.g. A client might remember a traumatic event and think “I am worthless”, or” I am evil”. The therapist then works with the client to develop a plausible potential belief, such as “ I can learn from this.” or “ I did the best I could under the circumstances”, or “I can find forgiveness.”) These or many other possible ways of understanding the events are discussed with the client as goals to find emotional resonance that is worked toward with EMDR. It must be noted that these understandings could include spiritual and/or philosophical beliefs, and evocation of the internalized beliefs of figures the client respects. Litz et al propose similar activity in the later stages of their 8 step “moral injury” intervention. There are some other overlaps, which we cannot call borrowing by Litz et al. because there is not indication in their work that they are aware of EMDR, but it is at least the failure to fully consider the precedent literature.

It should also be mentioned that in Shapiro’s (& Forest, 1997) book, describing a variety of cases, that there is an extensive report of her successful treatment of a combat veteran for the debilitating guilt related to the death of a prisoner being held by his unit.

For the authors to miss EMDR in surveying the field before offering their own treatment approach seems to reflect a lack of a required openness to precedent, which makes it difficult to consider their work a result of true scientific inquiry.

In a future post I hope to present some ideas on the question of the use of the term “injury” in this context. Litz et al. do say they do not want to medicalize these issues, however, I don’t know if you can use their terminology and not do so. It is a complex and difficult issue, on which which I hope to be able to share useful thoughts.

Karlin, B.E. & Cross, G. (2014) From the laboratory to the therapy room. American Psychologist, 60 (1), 19 – 33

Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P, Silva, C.& Maguen, Shira (2009) Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29, 695 – 706

Shapiro, F. & Forest, M. (1997) EMDR: The Breakthrough Therapy for Overcoming Anxiety, Stress, and Trauma. New York: Basic Books.

Part 2

Hamlet (to Polonius) Good my lord, will you see the players well bestowed?…
Polonius: My lord, I will use them according to their desert.
Hamlet: Use every man after his desert, and who should ’scape whipping?
Hamlet II 2

What is wrong with the phrase “moral injury”?
If we are to have a label for the category of problems related to the destructive psychological effects following harming or believing you have harmed others, it should not be “moral injury”. As Shakespeare’s quote suggests the injury would apply to us all, thus not of much use. If we consider “moral injury” as only applying to some, then, perhaps the difference is between those who know it and those who don’t. We could then divide the world between Poloniuses (who don’t know it) and Hamlets (who know it). And, then subdivide the Hamlets between pre/not-symptomatic and symptomatic. In Hamlet’s case the symptoms would have to be considered to have started after the father-murdered/mother-remarried trauma.

Furthermore, in that the designation “moral injury” is being applied in psychotherapeutic practice, specifically to people looking for help because of depression or symptoms usually considered part of PTSD, then the “moral injury” label is likely to be counter-productive. As a therapist, I have often tried to help people whose feelings of guilt over destructive actions (or inaction) have interfered with their being able to lead productive lives, and even potentiated the negative effects of their regretted behavior. But, I think categorizing them as having been morally injured would make many think I was treating them as the primary victim of their behavior, which they would find grossly insensitive.

What is the alternative?
If you are going to attack a term that has a use, as how “moral injury“ helps make the portion of mental health professionals stuck exclusively in the fear based understanding of the destructive psychological effects of trauma, then you are responsible for offering an improvement.

I have not been able to come up with anything that has the aesthetic fluidity of ”moral injury”, so far the best I can do is “trauma potentiating guilt”. I think it does not judge whether or not regretted acts should be considered an injury to the actor, but rather makes the focus helping people do what is worthwhile, given their experience. Psychotherapy relating to these issues is complex and I will not try to describe in detail here. It alluded to in the previous post in the discussion of EMDR and in some detail in EMDR and Psychotherapy Integration.  I plan on updating and elaborating on those ideas in a later post.

The Preferred Emotion and the Use of Assessment Questions in the History and Preparation Phases of Standard EMDR.

This paper has appeared in various forms for over five years. Earlier versions failed to find a home in professional journals. The current version is a hybrid of those earlier attempts but contains some informalities, since there is no longer any expectation of such publication.

The Preferred Emotion and the Use of Assessment Questions in the History and Preparation Phases of Standard EMDR.

(8.25.17 draft)

Abstract

This paper proposes two modifications in the standard EMDR eight phase protocol: (1) the establishment of a preferred emotion with the question, “When you think of this event what emotion would you prefer to be experiencing?” (2) the use of this, and most other “Assessment” phase questions in the “History” phase. The clinical and theoretical rationale for, and implications of, these modifications are discussed.

Preferred Emotion for Blogsite2

 

The Definition of EMDR

Let’s start with a fairly circumscribed mild point. We need a new definition of EMDR, one that does not begin with “…evidence based …” or “…successful outcomes well documented …”, as occur in EMDRIA’s official definition. Those aren’t phrases you find in a definition, you find them in an evaluation or a press release. In addition, “evidence based” suggests that EMDR was developed from research demonstrating the effectiveness of its various aspects. It wasn’t, but more on that later.

I have a definition in which more is different from EMDRIA’s than just the absence of self praise. I don’t think my proposal is perfect, but so far it is the least bad one I know of. It should also be mentioned that a version of the one below was submitted to EMDRIA during the latest development of the EMDR definition and it was rejected. But, that doesn’t mean the discussion should be over, or that someone could not use mine if they needed one that focused on essential features.

And, here it is: Eye Movement Desensitization and Reprocessing (EMDR) is a method of psychotherapy in which aspects of a target associative network (usually a troubling memory) including visual images, thoughts, feeling, emotions, are identified, as are a preferred thought about the self when target memory is active. The believability of the preferred thought is rated, as is the level of distress felt as the troubling memory is activated before initiated eye movement.

With the painful aspects of the problem memory again brought to awareness, the client is asked to free associate while moving her or his eyes following the therapist lead, in a repeated pattern for a period of time, determined by client response, but usually about 30 seconds. After the set of eye movement, the client is asked to report on the current content of consciousness, and then eye movement is reinitiated. This pattern is repeated until distress associated with the target network is resolved, and, hopefully, adaptive associations are connected to the targeted event. In its most complete form all aspects of the target memory(ies) are addressed, including related past events and possible future situations which may elicit related psychopathological responses.

Therapist comments between sets of eye movement are limited to brief instructions, unless the client is not progressing by either becoming aware of new material or not having decreased distress. In these cases a variety of interventions, many typical of other methods of psychotherapy may be made before eye movements are resumed.

There are many variations to specific aspects of the above activities, including on what the client is supposed to try to keep in mind as em begins. These variations are determined by client response, experience and research.

As in standard psychotherapy practice negotiation of treatment contract, client evaluation, history taking, building of rapport, explanation of method, and development of stress management strategies are part of treatment.

And now a short dictionary/elevator definition:

EMDR (Eye Movement Desensitization and Reprocessing) – a method of psychotherapy which usually involves recalling a troubling experience and engaging in therapist led repetitive back and forth eye movements or other sensory/motor activity. The rest is commentary.

I was just kidding about the commentary part. This subtle reference to Rabbi Hillel’s effort to explain his religion while standing on one leg obviously doesn’t belong in a definition. However, it should also note that Rabbi Hillel is reputed to have also suggested that the commentary should be studied.

Response to a potential objection:

I can foresee objection to the phrase: “including on what the client is supposed to try to keep in mind as eye movement begins”. The allowance of the loosening of the protocol comes from clinical practice. Let’s say before the first set of eye movement, when the therapist asks the client to put in mind a picture of the worst part of the target memory, the client has an immediate strong emotional reaction, and the therapist then begins the eye movement. Since the client has already been prepared for eye movement at this point most experienced therapists I have asked would just begin it. Would this not be EMDR because most of the Assessment phase was skipped over?

There will never be a fully satisfactory definition of EMDR, and this is a problem with almost all terms in the mental health field including such basic terms as “mental health” and “psychotherapy”. So we have to pick compromises that are most useful and least problematic.

Integrating EMDR into Clinical Work

The attached paper is especially for new EMDR practitioners. It indicates that I practice at  the North Chicago VA Medical Center. I still do a little work there, but it is now called the Captain James S. Lovell Federal Heath Care Center.

EMDR Clinician Survey

In 1992 an extensive survey was sent to the 1200 clinicians Francine Shapiro had trained asking about their clinical experience with EMDR. EMDR was new and it would take a while before many randomized controlled studies would be available (actually there were very few RTCs of method of therapy for the effects of trauma then), so it seemed important that there be information available about the effects of EMDR from independent sources . In addition there was the important, and not often seen, establishment of a body of clinical “lore” that would be based on a systematic collection of data, not just the passing on of clinical impressions, which is/was a common way clinicians receive our information. So, here is the survey, only ever published in the now out of print first edition of Shapiro’s basic text, Eye Movement Desensitization and Reprocessing (1995).

Integrative Model of Psychotherapy – The Four Activity Model

The attached paper describes The Four Activity Model (FAM) of psychotherapy and its application to EMDR and other methods (just like the title suggests). The model is more fully elaborated in the book EMDR and Psychotherapy Integration.

Overview of EMDR

The attached paper is a variation of my entry in Charles Figley’s (2012) Encyclopedia of Trauma: An Interdisciplinary Approach.